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lsquoPearls of Wisdomrsquo Retraction Pockets amp Tympanic Membrane Perforations
Gavin Morrison St Thomasrsquo amp Evelina Childrenrsquos Hospital
British Paediatric Otolaryngology Course Glasgow
12th March 2015
Pearls
Retraction Pockets Classifications
bull Attic Tos amp Poulsen (1980)
bull Pars Tensa Sade (1979)
Classification - Attic Retractions (Tos amp Poulsen)
bull Type 1 Retraction towards neck of malleus but airspace visible
bull Type 2 Retraction onto neck of malleus - no airspace visible behind membrane
bull Type 3 Retraction extends beyond osseous malleus full extent seen
bull Type 4 Erosion of outer attic wall
Type 1 Type 2
Type 3 Type 4
Classification ndash Pars Tensa Retractions (Sade)
bull Stage 1 - Mild retraction
bull Stage 2 - Retraction onto incudo-stapedial joint
bull Stage 3 - Retraction onto promontory bull Stage 4 - Adhesion of pars tensa to medial wall
In stage 3 the tympanic membrane can be lifted off the middle ear medial wall whereas in stage 4 it is not possible
What grades of Attic amp P Tensa Retractions are shown here
Erasmus Surgical Classification (Rotterdam)
bull I Atelectasis of TM
bull II Fixed to Promontory
bull III Fixed to IncusStapes
bull IV Deep pocket - limits not visible
bull V Deep pocket as IV with cholesteatoma
Management Options for Attic Retraction Pockets
bull Conservative ndash Observation amp serial audiometry +- CT scan
ndash Microsuction amp topical treatments
bull Surgical ndash ldquoOpenrdquo ndash atticotomy surgery
ndash ldquoClosedrdquo ndash Combined approach Tympano-mastoidectomy with attic reconstruction
Surgery for P flaccida retractions if
bull Limits not visible Type 3 4 amp hearing loss
ndash AND
bull Kertain build up
ndash OR
bull Intermittent scanty infections
Examples Attic retractions
What would you do
Stable vs Unstable
Stable = ldquoDryrdquo
bull Non-erosive non progressive
bull Not getting infections
bull No build up of keratin
CONSERVATIVE - IF GOOD HEARING
Unstable Attic Retraction
OPERATE
Pars Tensa Retractions
Pars Tensa Retractions
Dilemma
Early Surgery vs Late Surgery
Avoid ossicle erosion May get Hearing loss
Prevent Colesteatoma May get cholesteatoma
Can cause worse hearing
Management Options for Pars Tensa Retraction Pockets
bull Conservative ndash Observation amp serial audiometry +- CT
bull Surgical ndash Ventilation tube
ndash Excision of Pocket alone
ndash Excision of pocket with grafting
ndash Excision +- graft + Grommet
ndash Cartilage reinforcement tympanoplasty
Can the Literature give us the answers
helliphelliphelliphelliphelliphellip
Pars tensa Retractions in children by excision and ventilation tubes
bull Srinivasan V et al - Clin Otolaryngol Allied Sci 2000 25(4)253-6
bull 74 TM healing
bull 22 Re-retraction
Cochrane Review ndash Surgery for Tympanic Membrane Retraction Pockets
bull Nankivell PC and Pothier DD
bull 2010
bull 42 studies ndash 2 RCTs
bull Barbara 2008 (attic reconstruction) amp Elsheikh 2006 (pars tensa repair + - T tube)
bull ldquoNo statistical benefit of surgical interventionrdquo
bull ldquoThere is currently no good evidence for the role of any individual surgical intervention for the management of atelectasis of the tympanic membranerdquo
BUT
bull One Year Follow up only
bull No mention of attic retraction even though one paper only concerned this
Pars Tensa retractions - Natural History
bull TARGET trial ndash MISLEADING bull Retractions are spontaneously variable with time and may be reversible
bull Postero-superior retractions lead to 1o acquired
cholesteatomas (Sudhoff HolgerTos Mirko Pathogenesis of Attic Cholesteatoma Clinical
and Immunohistochemical Support for Combination of Retraction Theory and Proliferation Theory American Journal of Otology 2000 21(6)786-792)
Examples Pars Tensa retractions
Pars tensa retraction - What are you going to do
What are you going to do
How do you know if this retraction is going to progress
Grommets for Pars tensa retraction Pockets if under 10 and
bull Stage 1 and hearing loss from OME
bull Stage 2 and hearing loss or GENUINE erosion of LPI noted
bull Stage 3 with HL
bull Atelectasis Stage 4
Strategy for Pars Tensa Retractions
bull Use otoendoscope if limit not seen
bull Younger child ndash Repeated Ventilation tubes of hearing loss
bull Older child ndash consider excision amp grafting
bull Always montior the ME pressure -ve = delay surgery
bull Progressive or unstable poster-superior retraction - Operate
bull If hearing loss ndash offer surgery
bull Decision also depends on status of contralat ear age of patient amp historic
rate of progression
Reconstructive surgery for P tensa retraction if
bull Grade III retraction when adolescent
bull Retraction limits not seen in facial recess sinus tympani and unstable ndash periodic infections
bull Retraction into facial recess sinus tympani amp tympanogram improving
bull Grade IV retraction when adolescent
Mild retractionGood hearing
Pars tensa retraction pocket Atelectasiscollapse
Deep retractionEarly LPI erosion
Good or bad hearing
grommets
Glue earHearing loss
Trial grommets
Unstable retractionLimit of pocket out of view
Ossicular erosion
Reinforcement tympanoplasty+- ossiculoplasty
+- long term ventilation tube
Observation extrudes
Resolved discharge patient
lt10 years gt10 years
Failure
Summary
bull Classifications described
bull Vent Tubes correct Ptensa retractn while in situ
bull Postero-superior pockets can erode ossicles amp develop cholesteatoma
bull Surgery can be preventative or corrective
bull Operate if poor hearing or progression over time
bull Balance risks of surgery vs risks of non-intervention
bull Cartilage repair has gained popularity
Perforations
Safe vs Unsafe ears
bull Brain abscess
After cholesteatoma in 46
After mucosal disease in 38
After mod Rad mastoidectomy in 15
Browning GG The Unsafeness of safe ears JLO 1984a 9823-26
Aetiologies of TM Perforations
bull AOM perforation bull Otitis Externa ndash myringitis (fungal) bull CSOM bull Specific Chronic Suppurative Otitis Media TB Actinomyces Syphilis
bull Direct trauma to membrane bull Post ventilation tubes (275 ear 46 child 13 t-tubes)
bull Barotraumatic bull Blast Injury beware implantation
cholesteatoma
Size Matters
bull Conductive Hearing Loss variable 0 ndash 50 dB
bull Larger perforation = larger ABG
bull Low frequencies greatest affected
bull Post frac12 TM ndash transmits low frequency
bull Ant frac12 TM transmits high frequency
Management of TM perforations
bull Conservative ldquoA small perforation is good it acts as a natural ventilation
tuberdquo
Small hole no infections good hearing poor ETD = leave alone
bull Surgical ldquoThe perforation is bad it leads to recurrent ear infections
and restricts water sportsrdquo
Recurrent infections hearing loss other ear good = repair
Management of TM perforations
bull Conservative
bull Swabs + microsuction
bull Keep ear dry (earplugs for swimming)
bull Topical Agents - Ofloxacin or Ciprofloxacin drops + steroids
bull Systemic antibiotics
Management of TM perforations
bull Surgical
ndash Myringoplasty Tympanoplasty
ndash + - Adenoidectomy
Indications for repair of perforation
bull Any Ear with cholesteatoma
bull Not healed spontaneously after 6 months observation
andhellip
bull Recurrent otorrhoea
bull Disabling conductive hearing loss bull Bilateral ( gt30 - 40 dB)
bull Unilateral
bull To allow watersports
Wullstein Classification of Tympanoplasty (1956)
bull Type I ndash Myringoplasty = 3 ossicles present amp drum repair
bull Type II ndash Malleusincus eroded ndash reconstruction preserves middle ear depth
bull Type III ndash Lateral ossicles gone graft onto stapes superstructure columella effect shallow ME cleft
bull Type IV ndash No ossicles graft onto footplate
bull Type V ndash graft onto fixed footplate Va = fenestration of LSSC
Tympoanoplasty Type 1 in children ndash an evaluative study
bull Gautam Bir Sing et al Int J Ped Otorninolaryngol 200569 (8)1071-76
bull 80 graft success rate at 6 month
bull 61 significant improved hearing
Meta-analysis of Pediatric Tympanoplasty
bull Vrabec et al Arch Otolaryngol H amp Neck Surg 1999 125 (5) 530-34
bull Graft take rate 80 in perf less than half TM
69 if over half TM
bull Take rate with good vs poor ET function 87 cf 77
bull Adenoids ndash no difference
bull Normal contralat ear vs abnormal 80 cf 71
bull Wet ear ndash no difference
bull Increased success rate with increasing Age (p =0005)
What Age to perform myringoplasty
bull Success rate not influenced by age (eg House Ear Institute
Chandrasekhar et al Arch Oto HampN Surg 1995 121873-878 and Denoyelle Garabedien group Paris Laryngoscope)
bull Mean age of most paediatric published series = 10 ndash 11 years (range 4 ndash 17)
bull General Advice (GMorrison) ndash Other ear predicts outcome ndash 7 ndash 8 yrs or over if infections controllable and one good
hearing ear ndash As early as 3 ndash 4 if bilat Subtotal perfs with disabling
hearing loss amp infections
Myringoplasty ndash Personal Surgical tips
bull Consider periosteum graft
bull Dry graft thoroughly
bull Trim graft to exact size (little finger nail)
bull Underlay or reverse thru-lay technique
bull ldquoKerrrdquo ant wall pocket if no anterior lip
bull Subcuticular resorbable sutures
bull BIPP pack(s) except v young
EAM
ME
Anterior
Cartilage Tympanoplasty
bull Jansen 1958
bull Heerman 1962 ndash cartilage palisade
bull Techniques
ndash Island graft
ndash Palisades
ndash Butterfly inlay
ndash Cartilage Shield
Indications for Cartilage Tympanoplasty
bull Retraction pockets
bull Atelectasis
bull Poor ET Function
bull To prevent prosthesis extrusion
bull (Revision Surgery)
Reinforcement Tympanoplasty for retraction
Post Cartilage Tympanoplasty amp Incus transposition
Surgical Outcomes for Paediatric Myringoplasty
bull Fat plug Myringoplasty ndash 80 success bull Paper - steristrip myringoplasty ndash 65 bull Formal Myringoplasty - over 80 closure - 60 - 81 hearing
success bull Hearing gain - ABG to lt 10 dB to 23 lt20 dB in 883
Risk of OME after repair ndash 78 Long term graft breakdown ndash 65
Wet Ear Surgery
bull Moist ear ndash OK
bull Purulent Ear ndash Surgery Contraindicated
Conclusions
bull AOM and CSOM without cholesteatoma can lead to intracranial complications
bull Persistent perforations post grommets are seen in up to 46 patients
bull Operate when ET function improved
bull Cartilage Tympanoplasty has advantages in special cases
bull You can routinely repair ears at 8 years
bull Surgery best avoided in a purulent ear
Thank You
Pearls
Retraction Pockets Classifications
bull Attic Tos amp Poulsen (1980)
bull Pars Tensa Sade (1979)
Classification - Attic Retractions (Tos amp Poulsen)
bull Type 1 Retraction towards neck of malleus but airspace visible
bull Type 2 Retraction onto neck of malleus - no airspace visible behind membrane
bull Type 3 Retraction extends beyond osseous malleus full extent seen
bull Type 4 Erosion of outer attic wall
Type 1 Type 2
Type 3 Type 4
Classification ndash Pars Tensa Retractions (Sade)
bull Stage 1 - Mild retraction
bull Stage 2 - Retraction onto incudo-stapedial joint
bull Stage 3 - Retraction onto promontory bull Stage 4 - Adhesion of pars tensa to medial wall
In stage 3 the tympanic membrane can be lifted off the middle ear medial wall whereas in stage 4 it is not possible
What grades of Attic amp P Tensa Retractions are shown here
Erasmus Surgical Classification (Rotterdam)
bull I Atelectasis of TM
bull II Fixed to Promontory
bull III Fixed to IncusStapes
bull IV Deep pocket - limits not visible
bull V Deep pocket as IV with cholesteatoma
Management Options for Attic Retraction Pockets
bull Conservative ndash Observation amp serial audiometry +- CT scan
ndash Microsuction amp topical treatments
bull Surgical ndash ldquoOpenrdquo ndash atticotomy surgery
ndash ldquoClosedrdquo ndash Combined approach Tympano-mastoidectomy with attic reconstruction
Surgery for P flaccida retractions if
bull Limits not visible Type 3 4 amp hearing loss
ndash AND
bull Kertain build up
ndash OR
bull Intermittent scanty infections
Examples Attic retractions
What would you do
Stable vs Unstable
Stable = ldquoDryrdquo
bull Non-erosive non progressive
bull Not getting infections
bull No build up of keratin
CONSERVATIVE - IF GOOD HEARING
Unstable Attic Retraction
OPERATE
Pars Tensa Retractions
Pars Tensa Retractions
Dilemma
Early Surgery vs Late Surgery
Avoid ossicle erosion May get Hearing loss
Prevent Colesteatoma May get cholesteatoma
Can cause worse hearing
Management Options for Pars Tensa Retraction Pockets
bull Conservative ndash Observation amp serial audiometry +- CT
bull Surgical ndash Ventilation tube
ndash Excision of Pocket alone
ndash Excision of pocket with grafting
ndash Excision +- graft + Grommet
ndash Cartilage reinforcement tympanoplasty
Can the Literature give us the answers
helliphelliphelliphelliphelliphellip
Pars tensa Retractions in children by excision and ventilation tubes
bull Srinivasan V et al - Clin Otolaryngol Allied Sci 2000 25(4)253-6
bull 74 TM healing
bull 22 Re-retraction
Cochrane Review ndash Surgery for Tympanic Membrane Retraction Pockets
bull Nankivell PC and Pothier DD
bull 2010
bull 42 studies ndash 2 RCTs
bull Barbara 2008 (attic reconstruction) amp Elsheikh 2006 (pars tensa repair + - T tube)
bull ldquoNo statistical benefit of surgical interventionrdquo
bull ldquoThere is currently no good evidence for the role of any individual surgical intervention for the management of atelectasis of the tympanic membranerdquo
BUT
bull One Year Follow up only
bull No mention of attic retraction even though one paper only concerned this
Pars Tensa retractions - Natural History
bull TARGET trial ndash MISLEADING bull Retractions are spontaneously variable with time and may be reversible
bull Postero-superior retractions lead to 1o acquired
cholesteatomas (Sudhoff HolgerTos Mirko Pathogenesis of Attic Cholesteatoma Clinical
and Immunohistochemical Support for Combination of Retraction Theory and Proliferation Theory American Journal of Otology 2000 21(6)786-792)
Examples Pars Tensa retractions
Pars tensa retraction - What are you going to do
What are you going to do
How do you know if this retraction is going to progress
Grommets for Pars tensa retraction Pockets if under 10 and
bull Stage 1 and hearing loss from OME
bull Stage 2 and hearing loss or GENUINE erosion of LPI noted
bull Stage 3 with HL
bull Atelectasis Stage 4
Strategy for Pars Tensa Retractions
bull Use otoendoscope if limit not seen
bull Younger child ndash Repeated Ventilation tubes of hearing loss
bull Older child ndash consider excision amp grafting
bull Always montior the ME pressure -ve = delay surgery
bull Progressive or unstable poster-superior retraction - Operate
bull If hearing loss ndash offer surgery
bull Decision also depends on status of contralat ear age of patient amp historic
rate of progression
Reconstructive surgery for P tensa retraction if
bull Grade III retraction when adolescent
bull Retraction limits not seen in facial recess sinus tympani and unstable ndash periodic infections
bull Retraction into facial recess sinus tympani amp tympanogram improving
bull Grade IV retraction when adolescent
Mild retractionGood hearing
Pars tensa retraction pocket Atelectasiscollapse
Deep retractionEarly LPI erosion
Good or bad hearing
grommets
Glue earHearing loss
Trial grommets
Unstable retractionLimit of pocket out of view
Ossicular erosion
Reinforcement tympanoplasty+- ossiculoplasty
+- long term ventilation tube
Observation extrudes
Resolved discharge patient
lt10 years gt10 years
Failure
Summary
bull Classifications described
bull Vent Tubes correct Ptensa retractn while in situ
bull Postero-superior pockets can erode ossicles amp develop cholesteatoma
bull Surgery can be preventative or corrective
bull Operate if poor hearing or progression over time
bull Balance risks of surgery vs risks of non-intervention
bull Cartilage repair has gained popularity
Perforations
Safe vs Unsafe ears
bull Brain abscess
After cholesteatoma in 46
After mucosal disease in 38
After mod Rad mastoidectomy in 15
Browning GG The Unsafeness of safe ears JLO 1984a 9823-26
Aetiologies of TM Perforations
bull AOM perforation bull Otitis Externa ndash myringitis (fungal) bull CSOM bull Specific Chronic Suppurative Otitis Media TB Actinomyces Syphilis
bull Direct trauma to membrane bull Post ventilation tubes (275 ear 46 child 13 t-tubes)
bull Barotraumatic bull Blast Injury beware implantation
cholesteatoma
Size Matters
bull Conductive Hearing Loss variable 0 ndash 50 dB
bull Larger perforation = larger ABG
bull Low frequencies greatest affected
bull Post frac12 TM ndash transmits low frequency
bull Ant frac12 TM transmits high frequency
Management of TM perforations
bull Conservative ldquoA small perforation is good it acts as a natural ventilation
tuberdquo
Small hole no infections good hearing poor ETD = leave alone
bull Surgical ldquoThe perforation is bad it leads to recurrent ear infections
and restricts water sportsrdquo
Recurrent infections hearing loss other ear good = repair
Management of TM perforations
bull Conservative
bull Swabs + microsuction
bull Keep ear dry (earplugs for swimming)
bull Topical Agents - Ofloxacin or Ciprofloxacin drops + steroids
bull Systemic antibiotics
Management of TM perforations
bull Surgical
ndash Myringoplasty Tympanoplasty
ndash + - Adenoidectomy
Indications for repair of perforation
bull Any Ear with cholesteatoma
bull Not healed spontaneously after 6 months observation
andhellip
bull Recurrent otorrhoea
bull Disabling conductive hearing loss bull Bilateral ( gt30 - 40 dB)
bull Unilateral
bull To allow watersports
Wullstein Classification of Tympanoplasty (1956)
bull Type I ndash Myringoplasty = 3 ossicles present amp drum repair
bull Type II ndash Malleusincus eroded ndash reconstruction preserves middle ear depth
bull Type III ndash Lateral ossicles gone graft onto stapes superstructure columella effect shallow ME cleft
bull Type IV ndash No ossicles graft onto footplate
bull Type V ndash graft onto fixed footplate Va = fenestration of LSSC
Tympoanoplasty Type 1 in children ndash an evaluative study
bull Gautam Bir Sing et al Int J Ped Otorninolaryngol 200569 (8)1071-76
bull 80 graft success rate at 6 month
bull 61 significant improved hearing
Meta-analysis of Pediatric Tympanoplasty
bull Vrabec et al Arch Otolaryngol H amp Neck Surg 1999 125 (5) 530-34
bull Graft take rate 80 in perf less than half TM
69 if over half TM
bull Take rate with good vs poor ET function 87 cf 77
bull Adenoids ndash no difference
bull Normal contralat ear vs abnormal 80 cf 71
bull Wet ear ndash no difference
bull Increased success rate with increasing Age (p =0005)
What Age to perform myringoplasty
bull Success rate not influenced by age (eg House Ear Institute
Chandrasekhar et al Arch Oto HampN Surg 1995 121873-878 and Denoyelle Garabedien group Paris Laryngoscope)
bull Mean age of most paediatric published series = 10 ndash 11 years (range 4 ndash 17)
bull General Advice (GMorrison) ndash Other ear predicts outcome ndash 7 ndash 8 yrs or over if infections controllable and one good
hearing ear ndash As early as 3 ndash 4 if bilat Subtotal perfs with disabling
hearing loss amp infections
Myringoplasty ndash Personal Surgical tips
bull Consider periosteum graft
bull Dry graft thoroughly
bull Trim graft to exact size (little finger nail)
bull Underlay or reverse thru-lay technique
bull ldquoKerrrdquo ant wall pocket if no anterior lip
bull Subcuticular resorbable sutures
bull BIPP pack(s) except v young
EAM
ME
Anterior
Cartilage Tympanoplasty
bull Jansen 1958
bull Heerman 1962 ndash cartilage palisade
bull Techniques
ndash Island graft
ndash Palisades
ndash Butterfly inlay
ndash Cartilage Shield
Indications for Cartilage Tympanoplasty
bull Retraction pockets
bull Atelectasis
bull Poor ET Function
bull To prevent prosthesis extrusion
bull (Revision Surgery)
Reinforcement Tympanoplasty for retraction
Post Cartilage Tympanoplasty amp Incus transposition
Surgical Outcomes for Paediatric Myringoplasty
bull Fat plug Myringoplasty ndash 80 success bull Paper - steristrip myringoplasty ndash 65 bull Formal Myringoplasty - over 80 closure - 60 - 81 hearing
success bull Hearing gain - ABG to lt 10 dB to 23 lt20 dB in 883
Risk of OME after repair ndash 78 Long term graft breakdown ndash 65
Wet Ear Surgery
bull Moist ear ndash OK
bull Purulent Ear ndash Surgery Contraindicated
Conclusions
bull AOM and CSOM without cholesteatoma can lead to intracranial complications
bull Persistent perforations post grommets are seen in up to 46 patients
bull Operate when ET function improved
bull Cartilage Tympanoplasty has advantages in special cases
bull You can routinely repair ears at 8 years
bull Surgery best avoided in a purulent ear
Thank You
Retraction Pockets Classifications
bull Attic Tos amp Poulsen (1980)
bull Pars Tensa Sade (1979)
Classification - Attic Retractions (Tos amp Poulsen)
bull Type 1 Retraction towards neck of malleus but airspace visible
bull Type 2 Retraction onto neck of malleus - no airspace visible behind membrane
bull Type 3 Retraction extends beyond osseous malleus full extent seen
bull Type 4 Erosion of outer attic wall
Type 1 Type 2
Type 3 Type 4
Classification ndash Pars Tensa Retractions (Sade)
bull Stage 1 - Mild retraction
bull Stage 2 - Retraction onto incudo-stapedial joint
bull Stage 3 - Retraction onto promontory bull Stage 4 - Adhesion of pars tensa to medial wall
In stage 3 the tympanic membrane can be lifted off the middle ear medial wall whereas in stage 4 it is not possible
What grades of Attic amp P Tensa Retractions are shown here
Erasmus Surgical Classification (Rotterdam)
bull I Atelectasis of TM
bull II Fixed to Promontory
bull III Fixed to IncusStapes
bull IV Deep pocket - limits not visible
bull V Deep pocket as IV with cholesteatoma
Management Options for Attic Retraction Pockets
bull Conservative ndash Observation amp serial audiometry +- CT scan
ndash Microsuction amp topical treatments
bull Surgical ndash ldquoOpenrdquo ndash atticotomy surgery
ndash ldquoClosedrdquo ndash Combined approach Tympano-mastoidectomy with attic reconstruction
Surgery for P flaccida retractions if
bull Limits not visible Type 3 4 amp hearing loss
ndash AND
bull Kertain build up
ndash OR
bull Intermittent scanty infections
Examples Attic retractions
What would you do
Stable vs Unstable
Stable = ldquoDryrdquo
bull Non-erosive non progressive
bull Not getting infections
bull No build up of keratin
CONSERVATIVE - IF GOOD HEARING
Unstable Attic Retraction
OPERATE
Pars Tensa Retractions
Pars Tensa Retractions
Dilemma
Early Surgery vs Late Surgery
Avoid ossicle erosion May get Hearing loss
Prevent Colesteatoma May get cholesteatoma
Can cause worse hearing
Management Options for Pars Tensa Retraction Pockets
bull Conservative ndash Observation amp serial audiometry +- CT
bull Surgical ndash Ventilation tube
ndash Excision of Pocket alone
ndash Excision of pocket with grafting
ndash Excision +- graft + Grommet
ndash Cartilage reinforcement tympanoplasty
Can the Literature give us the answers
helliphelliphelliphelliphelliphellip
Pars tensa Retractions in children by excision and ventilation tubes
bull Srinivasan V et al - Clin Otolaryngol Allied Sci 2000 25(4)253-6
bull 74 TM healing
bull 22 Re-retraction
Cochrane Review ndash Surgery for Tympanic Membrane Retraction Pockets
bull Nankivell PC and Pothier DD
bull 2010
bull 42 studies ndash 2 RCTs
bull Barbara 2008 (attic reconstruction) amp Elsheikh 2006 (pars tensa repair + - T tube)
bull ldquoNo statistical benefit of surgical interventionrdquo
bull ldquoThere is currently no good evidence for the role of any individual surgical intervention for the management of atelectasis of the tympanic membranerdquo
BUT
bull One Year Follow up only
bull No mention of attic retraction even though one paper only concerned this
Pars Tensa retractions - Natural History
bull TARGET trial ndash MISLEADING bull Retractions are spontaneously variable with time and may be reversible
bull Postero-superior retractions lead to 1o acquired
cholesteatomas (Sudhoff HolgerTos Mirko Pathogenesis of Attic Cholesteatoma Clinical
and Immunohistochemical Support for Combination of Retraction Theory and Proliferation Theory American Journal of Otology 2000 21(6)786-792)
Examples Pars Tensa retractions
Pars tensa retraction - What are you going to do
What are you going to do
How do you know if this retraction is going to progress
Grommets for Pars tensa retraction Pockets if under 10 and
bull Stage 1 and hearing loss from OME
bull Stage 2 and hearing loss or GENUINE erosion of LPI noted
bull Stage 3 with HL
bull Atelectasis Stage 4
Strategy for Pars Tensa Retractions
bull Use otoendoscope if limit not seen
bull Younger child ndash Repeated Ventilation tubes of hearing loss
bull Older child ndash consider excision amp grafting
bull Always montior the ME pressure -ve = delay surgery
bull Progressive or unstable poster-superior retraction - Operate
bull If hearing loss ndash offer surgery
bull Decision also depends on status of contralat ear age of patient amp historic
rate of progression
Reconstructive surgery for P tensa retraction if
bull Grade III retraction when adolescent
bull Retraction limits not seen in facial recess sinus tympani and unstable ndash periodic infections
bull Retraction into facial recess sinus tympani amp tympanogram improving
bull Grade IV retraction when adolescent
Mild retractionGood hearing
Pars tensa retraction pocket Atelectasiscollapse
Deep retractionEarly LPI erosion
Good or bad hearing
grommets
Glue earHearing loss
Trial grommets
Unstable retractionLimit of pocket out of view
Ossicular erosion
Reinforcement tympanoplasty+- ossiculoplasty
+- long term ventilation tube
Observation extrudes
Resolved discharge patient
lt10 years gt10 years
Failure
Summary
bull Classifications described
bull Vent Tubes correct Ptensa retractn while in situ
bull Postero-superior pockets can erode ossicles amp develop cholesteatoma
bull Surgery can be preventative or corrective
bull Operate if poor hearing or progression over time
bull Balance risks of surgery vs risks of non-intervention
bull Cartilage repair has gained popularity
Perforations
Safe vs Unsafe ears
bull Brain abscess
After cholesteatoma in 46
After mucosal disease in 38
After mod Rad mastoidectomy in 15
Browning GG The Unsafeness of safe ears JLO 1984a 9823-26
Aetiologies of TM Perforations
bull AOM perforation bull Otitis Externa ndash myringitis (fungal) bull CSOM bull Specific Chronic Suppurative Otitis Media TB Actinomyces Syphilis
bull Direct trauma to membrane bull Post ventilation tubes (275 ear 46 child 13 t-tubes)
bull Barotraumatic bull Blast Injury beware implantation
cholesteatoma
Size Matters
bull Conductive Hearing Loss variable 0 ndash 50 dB
bull Larger perforation = larger ABG
bull Low frequencies greatest affected
bull Post frac12 TM ndash transmits low frequency
bull Ant frac12 TM transmits high frequency
Management of TM perforations
bull Conservative ldquoA small perforation is good it acts as a natural ventilation
tuberdquo
Small hole no infections good hearing poor ETD = leave alone
bull Surgical ldquoThe perforation is bad it leads to recurrent ear infections
and restricts water sportsrdquo
Recurrent infections hearing loss other ear good = repair
Management of TM perforations
bull Conservative
bull Swabs + microsuction
bull Keep ear dry (earplugs for swimming)
bull Topical Agents - Ofloxacin or Ciprofloxacin drops + steroids
bull Systemic antibiotics
Management of TM perforations
bull Surgical
ndash Myringoplasty Tympanoplasty
ndash + - Adenoidectomy
Indications for repair of perforation
bull Any Ear with cholesteatoma
bull Not healed spontaneously after 6 months observation
andhellip
bull Recurrent otorrhoea
bull Disabling conductive hearing loss bull Bilateral ( gt30 - 40 dB)
bull Unilateral
bull To allow watersports
Wullstein Classification of Tympanoplasty (1956)
bull Type I ndash Myringoplasty = 3 ossicles present amp drum repair
bull Type II ndash Malleusincus eroded ndash reconstruction preserves middle ear depth
bull Type III ndash Lateral ossicles gone graft onto stapes superstructure columella effect shallow ME cleft
bull Type IV ndash No ossicles graft onto footplate
bull Type V ndash graft onto fixed footplate Va = fenestration of LSSC
Tympoanoplasty Type 1 in children ndash an evaluative study
bull Gautam Bir Sing et al Int J Ped Otorninolaryngol 200569 (8)1071-76
bull 80 graft success rate at 6 month
bull 61 significant improved hearing
Meta-analysis of Pediatric Tympanoplasty
bull Vrabec et al Arch Otolaryngol H amp Neck Surg 1999 125 (5) 530-34
bull Graft take rate 80 in perf less than half TM
69 if over half TM
bull Take rate with good vs poor ET function 87 cf 77
bull Adenoids ndash no difference
bull Normal contralat ear vs abnormal 80 cf 71
bull Wet ear ndash no difference
bull Increased success rate with increasing Age (p =0005)
What Age to perform myringoplasty
bull Success rate not influenced by age (eg House Ear Institute
Chandrasekhar et al Arch Oto HampN Surg 1995 121873-878 and Denoyelle Garabedien group Paris Laryngoscope)
bull Mean age of most paediatric published series = 10 ndash 11 years (range 4 ndash 17)
bull General Advice (GMorrison) ndash Other ear predicts outcome ndash 7 ndash 8 yrs or over if infections controllable and one good
hearing ear ndash As early as 3 ndash 4 if bilat Subtotal perfs with disabling
hearing loss amp infections
Myringoplasty ndash Personal Surgical tips
bull Consider periosteum graft
bull Dry graft thoroughly
bull Trim graft to exact size (little finger nail)
bull Underlay or reverse thru-lay technique
bull ldquoKerrrdquo ant wall pocket if no anterior lip
bull Subcuticular resorbable sutures
bull BIPP pack(s) except v young
EAM
ME
Anterior
Cartilage Tympanoplasty
bull Jansen 1958
bull Heerman 1962 ndash cartilage palisade
bull Techniques
ndash Island graft
ndash Palisades
ndash Butterfly inlay
ndash Cartilage Shield
Indications for Cartilage Tympanoplasty
bull Retraction pockets
bull Atelectasis
bull Poor ET Function
bull To prevent prosthesis extrusion
bull (Revision Surgery)
Reinforcement Tympanoplasty for retraction
Post Cartilage Tympanoplasty amp Incus transposition
Surgical Outcomes for Paediatric Myringoplasty
bull Fat plug Myringoplasty ndash 80 success bull Paper - steristrip myringoplasty ndash 65 bull Formal Myringoplasty - over 80 closure - 60 - 81 hearing
success bull Hearing gain - ABG to lt 10 dB to 23 lt20 dB in 883
Risk of OME after repair ndash 78 Long term graft breakdown ndash 65
Wet Ear Surgery
bull Moist ear ndash OK
bull Purulent Ear ndash Surgery Contraindicated
Conclusions
bull AOM and CSOM without cholesteatoma can lead to intracranial complications
bull Persistent perforations post grommets are seen in up to 46 patients
bull Operate when ET function improved
bull Cartilage Tympanoplasty has advantages in special cases
bull You can routinely repair ears at 8 years
bull Surgery best avoided in a purulent ear
Thank You
Classification - Attic Retractions (Tos amp Poulsen)
bull Type 1 Retraction towards neck of malleus but airspace visible
bull Type 2 Retraction onto neck of malleus - no airspace visible behind membrane
bull Type 3 Retraction extends beyond osseous malleus full extent seen
bull Type 4 Erosion of outer attic wall
Type 1 Type 2
Type 3 Type 4
Classification ndash Pars Tensa Retractions (Sade)
bull Stage 1 - Mild retraction
bull Stage 2 - Retraction onto incudo-stapedial joint
bull Stage 3 - Retraction onto promontory bull Stage 4 - Adhesion of pars tensa to medial wall
In stage 3 the tympanic membrane can be lifted off the middle ear medial wall whereas in stage 4 it is not possible
What grades of Attic amp P Tensa Retractions are shown here
Erasmus Surgical Classification (Rotterdam)
bull I Atelectasis of TM
bull II Fixed to Promontory
bull III Fixed to IncusStapes
bull IV Deep pocket - limits not visible
bull V Deep pocket as IV with cholesteatoma
Management Options for Attic Retraction Pockets
bull Conservative ndash Observation amp serial audiometry +- CT scan
ndash Microsuction amp topical treatments
bull Surgical ndash ldquoOpenrdquo ndash atticotomy surgery
ndash ldquoClosedrdquo ndash Combined approach Tympano-mastoidectomy with attic reconstruction
Surgery for P flaccida retractions if
bull Limits not visible Type 3 4 amp hearing loss
ndash AND
bull Kertain build up
ndash OR
bull Intermittent scanty infections
Examples Attic retractions
What would you do
Stable vs Unstable
Stable = ldquoDryrdquo
bull Non-erosive non progressive
bull Not getting infections
bull No build up of keratin
CONSERVATIVE - IF GOOD HEARING
Unstable Attic Retraction
OPERATE
Pars Tensa Retractions
Pars Tensa Retractions
Dilemma
Early Surgery vs Late Surgery
Avoid ossicle erosion May get Hearing loss
Prevent Colesteatoma May get cholesteatoma
Can cause worse hearing
Management Options for Pars Tensa Retraction Pockets
bull Conservative ndash Observation amp serial audiometry +- CT
bull Surgical ndash Ventilation tube
ndash Excision of Pocket alone
ndash Excision of pocket with grafting
ndash Excision +- graft + Grommet
ndash Cartilage reinforcement tympanoplasty
Can the Literature give us the answers
helliphelliphelliphelliphelliphellip
Pars tensa Retractions in children by excision and ventilation tubes
bull Srinivasan V et al - Clin Otolaryngol Allied Sci 2000 25(4)253-6
bull 74 TM healing
bull 22 Re-retraction
Cochrane Review ndash Surgery for Tympanic Membrane Retraction Pockets
bull Nankivell PC and Pothier DD
bull 2010
bull 42 studies ndash 2 RCTs
bull Barbara 2008 (attic reconstruction) amp Elsheikh 2006 (pars tensa repair + - T tube)
bull ldquoNo statistical benefit of surgical interventionrdquo
bull ldquoThere is currently no good evidence for the role of any individual surgical intervention for the management of atelectasis of the tympanic membranerdquo
BUT
bull One Year Follow up only
bull No mention of attic retraction even though one paper only concerned this
Pars Tensa retractions - Natural History
bull TARGET trial ndash MISLEADING bull Retractions are spontaneously variable with time and may be reversible
bull Postero-superior retractions lead to 1o acquired
cholesteatomas (Sudhoff HolgerTos Mirko Pathogenesis of Attic Cholesteatoma Clinical
and Immunohistochemical Support for Combination of Retraction Theory and Proliferation Theory American Journal of Otology 2000 21(6)786-792)
Examples Pars Tensa retractions
Pars tensa retraction - What are you going to do
What are you going to do
How do you know if this retraction is going to progress
Grommets for Pars tensa retraction Pockets if under 10 and
bull Stage 1 and hearing loss from OME
bull Stage 2 and hearing loss or GENUINE erosion of LPI noted
bull Stage 3 with HL
bull Atelectasis Stage 4
Strategy for Pars Tensa Retractions
bull Use otoendoscope if limit not seen
bull Younger child ndash Repeated Ventilation tubes of hearing loss
bull Older child ndash consider excision amp grafting
bull Always montior the ME pressure -ve = delay surgery
bull Progressive or unstable poster-superior retraction - Operate
bull If hearing loss ndash offer surgery
bull Decision also depends on status of contralat ear age of patient amp historic
rate of progression
Reconstructive surgery for P tensa retraction if
bull Grade III retraction when adolescent
bull Retraction limits not seen in facial recess sinus tympani and unstable ndash periodic infections
bull Retraction into facial recess sinus tympani amp tympanogram improving
bull Grade IV retraction when adolescent
Mild retractionGood hearing
Pars tensa retraction pocket Atelectasiscollapse
Deep retractionEarly LPI erosion
Good or bad hearing
grommets
Glue earHearing loss
Trial grommets
Unstable retractionLimit of pocket out of view
Ossicular erosion
Reinforcement tympanoplasty+- ossiculoplasty
+- long term ventilation tube
Observation extrudes
Resolved discharge patient
lt10 years gt10 years
Failure
Summary
bull Classifications described
bull Vent Tubes correct Ptensa retractn while in situ
bull Postero-superior pockets can erode ossicles amp develop cholesteatoma
bull Surgery can be preventative or corrective
bull Operate if poor hearing or progression over time
bull Balance risks of surgery vs risks of non-intervention
bull Cartilage repair has gained popularity
Perforations
Safe vs Unsafe ears
bull Brain abscess
After cholesteatoma in 46
After mucosal disease in 38
After mod Rad mastoidectomy in 15
Browning GG The Unsafeness of safe ears JLO 1984a 9823-26
Aetiologies of TM Perforations
bull AOM perforation bull Otitis Externa ndash myringitis (fungal) bull CSOM bull Specific Chronic Suppurative Otitis Media TB Actinomyces Syphilis
bull Direct trauma to membrane bull Post ventilation tubes (275 ear 46 child 13 t-tubes)
bull Barotraumatic bull Blast Injury beware implantation
cholesteatoma
Size Matters
bull Conductive Hearing Loss variable 0 ndash 50 dB
bull Larger perforation = larger ABG
bull Low frequencies greatest affected
bull Post frac12 TM ndash transmits low frequency
bull Ant frac12 TM transmits high frequency
Management of TM perforations
bull Conservative ldquoA small perforation is good it acts as a natural ventilation
tuberdquo
Small hole no infections good hearing poor ETD = leave alone
bull Surgical ldquoThe perforation is bad it leads to recurrent ear infections
and restricts water sportsrdquo
Recurrent infections hearing loss other ear good = repair
Management of TM perforations
bull Conservative
bull Swabs + microsuction
bull Keep ear dry (earplugs for swimming)
bull Topical Agents - Ofloxacin or Ciprofloxacin drops + steroids
bull Systemic antibiotics
Management of TM perforations
bull Surgical
ndash Myringoplasty Tympanoplasty
ndash + - Adenoidectomy
Indications for repair of perforation
bull Any Ear with cholesteatoma
bull Not healed spontaneously after 6 months observation
andhellip
bull Recurrent otorrhoea
bull Disabling conductive hearing loss bull Bilateral ( gt30 - 40 dB)
bull Unilateral
bull To allow watersports
Wullstein Classification of Tympanoplasty (1956)
bull Type I ndash Myringoplasty = 3 ossicles present amp drum repair
bull Type II ndash Malleusincus eroded ndash reconstruction preserves middle ear depth
bull Type III ndash Lateral ossicles gone graft onto stapes superstructure columella effect shallow ME cleft
bull Type IV ndash No ossicles graft onto footplate
bull Type V ndash graft onto fixed footplate Va = fenestration of LSSC
Tympoanoplasty Type 1 in children ndash an evaluative study
bull Gautam Bir Sing et al Int J Ped Otorninolaryngol 200569 (8)1071-76
bull 80 graft success rate at 6 month
bull 61 significant improved hearing
Meta-analysis of Pediatric Tympanoplasty
bull Vrabec et al Arch Otolaryngol H amp Neck Surg 1999 125 (5) 530-34
bull Graft take rate 80 in perf less than half TM
69 if over half TM
bull Take rate with good vs poor ET function 87 cf 77
bull Adenoids ndash no difference
bull Normal contralat ear vs abnormal 80 cf 71
bull Wet ear ndash no difference
bull Increased success rate with increasing Age (p =0005)
What Age to perform myringoplasty
bull Success rate not influenced by age (eg House Ear Institute
Chandrasekhar et al Arch Oto HampN Surg 1995 121873-878 and Denoyelle Garabedien group Paris Laryngoscope)
bull Mean age of most paediatric published series = 10 ndash 11 years (range 4 ndash 17)
bull General Advice (GMorrison) ndash Other ear predicts outcome ndash 7 ndash 8 yrs or over if infections controllable and one good
hearing ear ndash As early as 3 ndash 4 if bilat Subtotal perfs with disabling
hearing loss amp infections
Myringoplasty ndash Personal Surgical tips
bull Consider periosteum graft
bull Dry graft thoroughly
bull Trim graft to exact size (little finger nail)
bull Underlay or reverse thru-lay technique
bull ldquoKerrrdquo ant wall pocket if no anterior lip
bull Subcuticular resorbable sutures
bull BIPP pack(s) except v young
EAM
ME
Anterior
Cartilage Tympanoplasty
bull Jansen 1958
bull Heerman 1962 ndash cartilage palisade
bull Techniques
ndash Island graft
ndash Palisades
ndash Butterfly inlay
ndash Cartilage Shield
Indications for Cartilage Tympanoplasty
bull Retraction pockets
bull Atelectasis
bull Poor ET Function
bull To prevent prosthesis extrusion
bull (Revision Surgery)
Reinforcement Tympanoplasty for retraction
Post Cartilage Tympanoplasty amp Incus transposition
Surgical Outcomes for Paediatric Myringoplasty
bull Fat plug Myringoplasty ndash 80 success bull Paper - steristrip myringoplasty ndash 65 bull Formal Myringoplasty - over 80 closure - 60 - 81 hearing
success bull Hearing gain - ABG to lt 10 dB to 23 lt20 dB in 883
Risk of OME after repair ndash 78 Long term graft breakdown ndash 65
Wet Ear Surgery
bull Moist ear ndash OK
bull Purulent Ear ndash Surgery Contraindicated
Conclusions
bull AOM and CSOM without cholesteatoma can lead to intracranial complications
bull Persistent perforations post grommets are seen in up to 46 patients
bull Operate when ET function improved
bull Cartilage Tympanoplasty has advantages in special cases
bull You can routinely repair ears at 8 years
bull Surgery best avoided in a purulent ear
Thank You
Type 1 Type 2
Type 3 Type 4
Classification ndash Pars Tensa Retractions (Sade)
bull Stage 1 - Mild retraction
bull Stage 2 - Retraction onto incudo-stapedial joint
bull Stage 3 - Retraction onto promontory bull Stage 4 - Adhesion of pars tensa to medial wall
In stage 3 the tympanic membrane can be lifted off the middle ear medial wall whereas in stage 4 it is not possible
What grades of Attic amp P Tensa Retractions are shown here
Erasmus Surgical Classification (Rotterdam)
bull I Atelectasis of TM
bull II Fixed to Promontory
bull III Fixed to IncusStapes
bull IV Deep pocket - limits not visible
bull V Deep pocket as IV with cholesteatoma
Management Options for Attic Retraction Pockets
bull Conservative ndash Observation amp serial audiometry +- CT scan
ndash Microsuction amp topical treatments
bull Surgical ndash ldquoOpenrdquo ndash atticotomy surgery
ndash ldquoClosedrdquo ndash Combined approach Tympano-mastoidectomy with attic reconstruction
Surgery for P flaccida retractions if
bull Limits not visible Type 3 4 amp hearing loss
ndash AND
bull Kertain build up
ndash OR
bull Intermittent scanty infections
Examples Attic retractions
What would you do
Stable vs Unstable
Stable = ldquoDryrdquo
bull Non-erosive non progressive
bull Not getting infections
bull No build up of keratin
CONSERVATIVE - IF GOOD HEARING
Unstable Attic Retraction
OPERATE
Pars Tensa Retractions
Pars Tensa Retractions
Dilemma
Early Surgery vs Late Surgery
Avoid ossicle erosion May get Hearing loss
Prevent Colesteatoma May get cholesteatoma
Can cause worse hearing
Management Options for Pars Tensa Retraction Pockets
bull Conservative ndash Observation amp serial audiometry +- CT
bull Surgical ndash Ventilation tube
ndash Excision of Pocket alone
ndash Excision of pocket with grafting
ndash Excision +- graft + Grommet
ndash Cartilage reinforcement tympanoplasty
Can the Literature give us the answers
helliphelliphelliphelliphelliphellip
Pars tensa Retractions in children by excision and ventilation tubes
bull Srinivasan V et al - Clin Otolaryngol Allied Sci 2000 25(4)253-6
bull 74 TM healing
bull 22 Re-retraction
Cochrane Review ndash Surgery for Tympanic Membrane Retraction Pockets
bull Nankivell PC and Pothier DD
bull 2010
bull 42 studies ndash 2 RCTs
bull Barbara 2008 (attic reconstruction) amp Elsheikh 2006 (pars tensa repair + - T tube)
bull ldquoNo statistical benefit of surgical interventionrdquo
bull ldquoThere is currently no good evidence for the role of any individual surgical intervention for the management of atelectasis of the tympanic membranerdquo
BUT
bull One Year Follow up only
bull No mention of attic retraction even though one paper only concerned this
Pars Tensa retractions - Natural History
bull TARGET trial ndash MISLEADING bull Retractions are spontaneously variable with time and may be reversible
bull Postero-superior retractions lead to 1o acquired
cholesteatomas (Sudhoff HolgerTos Mirko Pathogenesis of Attic Cholesteatoma Clinical
and Immunohistochemical Support for Combination of Retraction Theory and Proliferation Theory American Journal of Otology 2000 21(6)786-792)
Examples Pars Tensa retractions
Pars tensa retraction - What are you going to do
What are you going to do
How do you know if this retraction is going to progress
Grommets for Pars tensa retraction Pockets if under 10 and
bull Stage 1 and hearing loss from OME
bull Stage 2 and hearing loss or GENUINE erosion of LPI noted
bull Stage 3 with HL
bull Atelectasis Stage 4
Strategy for Pars Tensa Retractions
bull Use otoendoscope if limit not seen
bull Younger child ndash Repeated Ventilation tubes of hearing loss
bull Older child ndash consider excision amp grafting
bull Always montior the ME pressure -ve = delay surgery
bull Progressive or unstable poster-superior retraction - Operate
bull If hearing loss ndash offer surgery
bull Decision also depends on status of contralat ear age of patient amp historic
rate of progression
Reconstructive surgery for P tensa retraction if
bull Grade III retraction when adolescent
bull Retraction limits not seen in facial recess sinus tympani and unstable ndash periodic infections
bull Retraction into facial recess sinus tympani amp tympanogram improving
bull Grade IV retraction when adolescent
Mild retractionGood hearing
Pars tensa retraction pocket Atelectasiscollapse
Deep retractionEarly LPI erosion
Good or bad hearing
grommets
Glue earHearing loss
Trial grommets
Unstable retractionLimit of pocket out of view
Ossicular erosion
Reinforcement tympanoplasty+- ossiculoplasty
+- long term ventilation tube
Observation extrudes
Resolved discharge patient
lt10 years gt10 years
Failure
Summary
bull Classifications described
bull Vent Tubes correct Ptensa retractn while in situ
bull Postero-superior pockets can erode ossicles amp develop cholesteatoma
bull Surgery can be preventative or corrective
bull Operate if poor hearing or progression over time
bull Balance risks of surgery vs risks of non-intervention
bull Cartilage repair has gained popularity
Perforations
Safe vs Unsafe ears
bull Brain abscess
After cholesteatoma in 46
After mucosal disease in 38
After mod Rad mastoidectomy in 15
Browning GG The Unsafeness of safe ears JLO 1984a 9823-26
Aetiologies of TM Perforations
bull AOM perforation bull Otitis Externa ndash myringitis (fungal) bull CSOM bull Specific Chronic Suppurative Otitis Media TB Actinomyces Syphilis
bull Direct trauma to membrane bull Post ventilation tubes (275 ear 46 child 13 t-tubes)
bull Barotraumatic bull Blast Injury beware implantation
cholesteatoma
Size Matters
bull Conductive Hearing Loss variable 0 ndash 50 dB
bull Larger perforation = larger ABG
bull Low frequencies greatest affected
bull Post frac12 TM ndash transmits low frequency
bull Ant frac12 TM transmits high frequency
Management of TM perforations
bull Conservative ldquoA small perforation is good it acts as a natural ventilation
tuberdquo
Small hole no infections good hearing poor ETD = leave alone
bull Surgical ldquoThe perforation is bad it leads to recurrent ear infections
and restricts water sportsrdquo
Recurrent infections hearing loss other ear good = repair
Management of TM perforations
bull Conservative
bull Swabs + microsuction
bull Keep ear dry (earplugs for swimming)
bull Topical Agents - Ofloxacin or Ciprofloxacin drops + steroids
bull Systemic antibiotics
Management of TM perforations
bull Surgical
ndash Myringoplasty Tympanoplasty
ndash + - Adenoidectomy
Indications for repair of perforation
bull Any Ear with cholesteatoma
bull Not healed spontaneously after 6 months observation
andhellip
bull Recurrent otorrhoea
bull Disabling conductive hearing loss bull Bilateral ( gt30 - 40 dB)
bull Unilateral
bull To allow watersports
Wullstein Classification of Tympanoplasty (1956)
bull Type I ndash Myringoplasty = 3 ossicles present amp drum repair
bull Type II ndash Malleusincus eroded ndash reconstruction preserves middle ear depth
bull Type III ndash Lateral ossicles gone graft onto stapes superstructure columella effect shallow ME cleft
bull Type IV ndash No ossicles graft onto footplate
bull Type V ndash graft onto fixed footplate Va = fenestration of LSSC
Tympoanoplasty Type 1 in children ndash an evaluative study
bull Gautam Bir Sing et al Int J Ped Otorninolaryngol 200569 (8)1071-76
bull 80 graft success rate at 6 month
bull 61 significant improved hearing
Meta-analysis of Pediatric Tympanoplasty
bull Vrabec et al Arch Otolaryngol H amp Neck Surg 1999 125 (5) 530-34
bull Graft take rate 80 in perf less than half TM
69 if over half TM
bull Take rate with good vs poor ET function 87 cf 77
bull Adenoids ndash no difference
bull Normal contralat ear vs abnormal 80 cf 71
bull Wet ear ndash no difference
bull Increased success rate with increasing Age (p =0005)
What Age to perform myringoplasty
bull Success rate not influenced by age (eg House Ear Institute
Chandrasekhar et al Arch Oto HampN Surg 1995 121873-878 and Denoyelle Garabedien group Paris Laryngoscope)
bull Mean age of most paediatric published series = 10 ndash 11 years (range 4 ndash 17)
bull General Advice (GMorrison) ndash Other ear predicts outcome ndash 7 ndash 8 yrs or over if infections controllable and one good
hearing ear ndash As early as 3 ndash 4 if bilat Subtotal perfs with disabling
hearing loss amp infections
Myringoplasty ndash Personal Surgical tips
bull Consider periosteum graft
bull Dry graft thoroughly
bull Trim graft to exact size (little finger nail)
bull Underlay or reverse thru-lay technique
bull ldquoKerrrdquo ant wall pocket if no anterior lip
bull Subcuticular resorbable sutures
bull BIPP pack(s) except v young
EAM
ME
Anterior
Cartilage Tympanoplasty
bull Jansen 1958
bull Heerman 1962 ndash cartilage palisade
bull Techniques
ndash Island graft
ndash Palisades
ndash Butterfly inlay
ndash Cartilage Shield
Indications for Cartilage Tympanoplasty
bull Retraction pockets
bull Atelectasis
bull Poor ET Function
bull To prevent prosthesis extrusion
bull (Revision Surgery)
Reinforcement Tympanoplasty for retraction
Post Cartilage Tympanoplasty amp Incus transposition
Surgical Outcomes for Paediatric Myringoplasty
bull Fat plug Myringoplasty ndash 80 success bull Paper - steristrip myringoplasty ndash 65 bull Formal Myringoplasty - over 80 closure - 60 - 81 hearing
success bull Hearing gain - ABG to lt 10 dB to 23 lt20 dB in 883
Risk of OME after repair ndash 78 Long term graft breakdown ndash 65
Wet Ear Surgery
bull Moist ear ndash OK
bull Purulent Ear ndash Surgery Contraindicated
Conclusions
bull AOM and CSOM without cholesteatoma can lead to intracranial complications
bull Persistent perforations post grommets are seen in up to 46 patients
bull Operate when ET function improved
bull Cartilage Tympanoplasty has advantages in special cases
bull You can routinely repair ears at 8 years
bull Surgery best avoided in a purulent ear
Thank You
Classification ndash Pars Tensa Retractions (Sade)
bull Stage 1 - Mild retraction
bull Stage 2 - Retraction onto incudo-stapedial joint
bull Stage 3 - Retraction onto promontory bull Stage 4 - Adhesion of pars tensa to medial wall
In stage 3 the tympanic membrane can be lifted off the middle ear medial wall whereas in stage 4 it is not possible
What grades of Attic amp P Tensa Retractions are shown here
Erasmus Surgical Classification (Rotterdam)
bull I Atelectasis of TM
bull II Fixed to Promontory
bull III Fixed to IncusStapes
bull IV Deep pocket - limits not visible
bull V Deep pocket as IV with cholesteatoma
Management Options for Attic Retraction Pockets
bull Conservative ndash Observation amp serial audiometry +- CT scan
ndash Microsuction amp topical treatments
bull Surgical ndash ldquoOpenrdquo ndash atticotomy surgery
ndash ldquoClosedrdquo ndash Combined approach Tympano-mastoidectomy with attic reconstruction
Surgery for P flaccida retractions if
bull Limits not visible Type 3 4 amp hearing loss
ndash AND
bull Kertain build up
ndash OR
bull Intermittent scanty infections
Examples Attic retractions
What would you do
Stable vs Unstable
Stable = ldquoDryrdquo
bull Non-erosive non progressive
bull Not getting infections
bull No build up of keratin
CONSERVATIVE - IF GOOD HEARING
Unstable Attic Retraction
OPERATE
Pars Tensa Retractions
Pars Tensa Retractions
Dilemma
Early Surgery vs Late Surgery
Avoid ossicle erosion May get Hearing loss
Prevent Colesteatoma May get cholesteatoma
Can cause worse hearing
Management Options for Pars Tensa Retraction Pockets
bull Conservative ndash Observation amp serial audiometry +- CT
bull Surgical ndash Ventilation tube
ndash Excision of Pocket alone
ndash Excision of pocket with grafting
ndash Excision +- graft + Grommet
ndash Cartilage reinforcement tympanoplasty
Can the Literature give us the answers
helliphelliphelliphelliphelliphellip
Pars tensa Retractions in children by excision and ventilation tubes
bull Srinivasan V et al - Clin Otolaryngol Allied Sci 2000 25(4)253-6
bull 74 TM healing
bull 22 Re-retraction
Cochrane Review ndash Surgery for Tympanic Membrane Retraction Pockets
bull Nankivell PC and Pothier DD
bull 2010
bull 42 studies ndash 2 RCTs
bull Barbara 2008 (attic reconstruction) amp Elsheikh 2006 (pars tensa repair + - T tube)
bull ldquoNo statistical benefit of surgical interventionrdquo
bull ldquoThere is currently no good evidence for the role of any individual surgical intervention for the management of atelectasis of the tympanic membranerdquo
BUT
bull One Year Follow up only
bull No mention of attic retraction even though one paper only concerned this
Pars Tensa retractions - Natural History
bull TARGET trial ndash MISLEADING bull Retractions are spontaneously variable with time and may be reversible
bull Postero-superior retractions lead to 1o acquired
cholesteatomas (Sudhoff HolgerTos Mirko Pathogenesis of Attic Cholesteatoma Clinical
and Immunohistochemical Support for Combination of Retraction Theory and Proliferation Theory American Journal of Otology 2000 21(6)786-792)
Examples Pars Tensa retractions
Pars tensa retraction - What are you going to do
What are you going to do
How do you know if this retraction is going to progress
Grommets for Pars tensa retraction Pockets if under 10 and
bull Stage 1 and hearing loss from OME
bull Stage 2 and hearing loss or GENUINE erosion of LPI noted
bull Stage 3 with HL
bull Atelectasis Stage 4
Strategy for Pars Tensa Retractions
bull Use otoendoscope if limit not seen
bull Younger child ndash Repeated Ventilation tubes of hearing loss
bull Older child ndash consider excision amp grafting
bull Always montior the ME pressure -ve = delay surgery
bull Progressive or unstable poster-superior retraction - Operate
bull If hearing loss ndash offer surgery
bull Decision also depends on status of contralat ear age of patient amp historic
rate of progression
Reconstructive surgery for P tensa retraction if
bull Grade III retraction when adolescent
bull Retraction limits not seen in facial recess sinus tympani and unstable ndash periodic infections
bull Retraction into facial recess sinus tympani amp tympanogram improving
bull Grade IV retraction when adolescent
Mild retractionGood hearing
Pars tensa retraction pocket Atelectasiscollapse
Deep retractionEarly LPI erosion
Good or bad hearing
grommets
Glue earHearing loss
Trial grommets
Unstable retractionLimit of pocket out of view
Ossicular erosion
Reinforcement tympanoplasty+- ossiculoplasty
+- long term ventilation tube
Observation extrudes
Resolved discharge patient
lt10 years gt10 years
Failure
Summary
bull Classifications described
bull Vent Tubes correct Ptensa retractn while in situ
bull Postero-superior pockets can erode ossicles amp develop cholesteatoma
bull Surgery can be preventative or corrective
bull Operate if poor hearing or progression over time
bull Balance risks of surgery vs risks of non-intervention
bull Cartilage repair has gained popularity
Perforations
Safe vs Unsafe ears
bull Brain abscess
After cholesteatoma in 46
After mucosal disease in 38
After mod Rad mastoidectomy in 15
Browning GG The Unsafeness of safe ears JLO 1984a 9823-26
Aetiologies of TM Perforations
bull AOM perforation bull Otitis Externa ndash myringitis (fungal) bull CSOM bull Specific Chronic Suppurative Otitis Media TB Actinomyces Syphilis
bull Direct trauma to membrane bull Post ventilation tubes (275 ear 46 child 13 t-tubes)
bull Barotraumatic bull Blast Injury beware implantation
cholesteatoma
Size Matters
bull Conductive Hearing Loss variable 0 ndash 50 dB
bull Larger perforation = larger ABG
bull Low frequencies greatest affected
bull Post frac12 TM ndash transmits low frequency
bull Ant frac12 TM transmits high frequency
Management of TM perforations
bull Conservative ldquoA small perforation is good it acts as a natural ventilation
tuberdquo
Small hole no infections good hearing poor ETD = leave alone
bull Surgical ldquoThe perforation is bad it leads to recurrent ear infections
and restricts water sportsrdquo
Recurrent infections hearing loss other ear good = repair
Management of TM perforations
bull Conservative
bull Swabs + microsuction
bull Keep ear dry (earplugs for swimming)
bull Topical Agents - Ofloxacin or Ciprofloxacin drops + steroids
bull Systemic antibiotics
Management of TM perforations
bull Surgical
ndash Myringoplasty Tympanoplasty
ndash + - Adenoidectomy
Indications for repair of perforation
bull Any Ear with cholesteatoma
bull Not healed spontaneously after 6 months observation
andhellip
bull Recurrent otorrhoea
bull Disabling conductive hearing loss bull Bilateral ( gt30 - 40 dB)
bull Unilateral
bull To allow watersports
Wullstein Classification of Tympanoplasty (1956)
bull Type I ndash Myringoplasty = 3 ossicles present amp drum repair
bull Type II ndash Malleusincus eroded ndash reconstruction preserves middle ear depth
bull Type III ndash Lateral ossicles gone graft onto stapes superstructure columella effect shallow ME cleft
bull Type IV ndash No ossicles graft onto footplate
bull Type V ndash graft onto fixed footplate Va = fenestration of LSSC
Tympoanoplasty Type 1 in children ndash an evaluative study
bull Gautam Bir Sing et al Int J Ped Otorninolaryngol 200569 (8)1071-76
bull 80 graft success rate at 6 month
bull 61 significant improved hearing
Meta-analysis of Pediatric Tympanoplasty
bull Vrabec et al Arch Otolaryngol H amp Neck Surg 1999 125 (5) 530-34
bull Graft take rate 80 in perf less than half TM
69 if over half TM
bull Take rate with good vs poor ET function 87 cf 77
bull Adenoids ndash no difference
bull Normal contralat ear vs abnormal 80 cf 71
bull Wet ear ndash no difference
bull Increased success rate with increasing Age (p =0005)
What Age to perform myringoplasty
bull Success rate not influenced by age (eg House Ear Institute
Chandrasekhar et al Arch Oto HampN Surg 1995 121873-878 and Denoyelle Garabedien group Paris Laryngoscope)
bull Mean age of most paediatric published series = 10 ndash 11 years (range 4 ndash 17)
bull General Advice (GMorrison) ndash Other ear predicts outcome ndash 7 ndash 8 yrs or over if infections controllable and one good
hearing ear ndash As early as 3 ndash 4 if bilat Subtotal perfs with disabling
hearing loss amp infections
Myringoplasty ndash Personal Surgical tips
bull Consider periosteum graft
bull Dry graft thoroughly
bull Trim graft to exact size (little finger nail)
bull Underlay or reverse thru-lay technique
bull ldquoKerrrdquo ant wall pocket if no anterior lip
bull Subcuticular resorbable sutures
bull BIPP pack(s) except v young
EAM
ME
Anterior
Cartilage Tympanoplasty
bull Jansen 1958
bull Heerman 1962 ndash cartilage palisade
bull Techniques
ndash Island graft
ndash Palisades
ndash Butterfly inlay
ndash Cartilage Shield
Indications for Cartilage Tympanoplasty
bull Retraction pockets
bull Atelectasis
bull Poor ET Function
bull To prevent prosthesis extrusion
bull (Revision Surgery)
Reinforcement Tympanoplasty for retraction
Post Cartilage Tympanoplasty amp Incus transposition
Surgical Outcomes for Paediatric Myringoplasty
bull Fat plug Myringoplasty ndash 80 success bull Paper - steristrip myringoplasty ndash 65 bull Formal Myringoplasty - over 80 closure - 60 - 81 hearing
success bull Hearing gain - ABG to lt 10 dB to 23 lt20 dB in 883
Risk of OME after repair ndash 78 Long term graft breakdown ndash 65
Wet Ear Surgery
bull Moist ear ndash OK
bull Purulent Ear ndash Surgery Contraindicated
Conclusions
bull AOM and CSOM without cholesteatoma can lead to intracranial complications
bull Persistent perforations post grommets are seen in up to 46 patients
bull Operate when ET function improved
bull Cartilage Tympanoplasty has advantages in special cases
bull You can routinely repair ears at 8 years
bull Surgery best avoided in a purulent ear
Thank You
What grades of Attic amp P Tensa Retractions are shown here
Erasmus Surgical Classification (Rotterdam)
bull I Atelectasis of TM
bull II Fixed to Promontory
bull III Fixed to IncusStapes
bull IV Deep pocket - limits not visible
bull V Deep pocket as IV with cholesteatoma
Management Options for Attic Retraction Pockets
bull Conservative ndash Observation amp serial audiometry +- CT scan
ndash Microsuction amp topical treatments
bull Surgical ndash ldquoOpenrdquo ndash atticotomy surgery
ndash ldquoClosedrdquo ndash Combined approach Tympano-mastoidectomy with attic reconstruction
Surgery for P flaccida retractions if
bull Limits not visible Type 3 4 amp hearing loss
ndash AND
bull Kertain build up
ndash OR
bull Intermittent scanty infections
Examples Attic retractions
What would you do
Stable vs Unstable
Stable = ldquoDryrdquo
bull Non-erosive non progressive
bull Not getting infections
bull No build up of keratin
CONSERVATIVE - IF GOOD HEARING
Unstable Attic Retraction
OPERATE
Pars Tensa Retractions
Pars Tensa Retractions
Dilemma
Early Surgery vs Late Surgery
Avoid ossicle erosion May get Hearing loss
Prevent Colesteatoma May get cholesteatoma
Can cause worse hearing
Management Options for Pars Tensa Retraction Pockets
bull Conservative ndash Observation amp serial audiometry +- CT
bull Surgical ndash Ventilation tube
ndash Excision of Pocket alone
ndash Excision of pocket with grafting
ndash Excision +- graft + Grommet
ndash Cartilage reinforcement tympanoplasty
Can the Literature give us the answers
helliphelliphelliphelliphelliphellip
Pars tensa Retractions in children by excision and ventilation tubes
bull Srinivasan V et al - Clin Otolaryngol Allied Sci 2000 25(4)253-6
bull 74 TM healing
bull 22 Re-retraction
Cochrane Review ndash Surgery for Tympanic Membrane Retraction Pockets
bull Nankivell PC and Pothier DD
bull 2010
bull 42 studies ndash 2 RCTs
bull Barbara 2008 (attic reconstruction) amp Elsheikh 2006 (pars tensa repair + - T tube)
bull ldquoNo statistical benefit of surgical interventionrdquo
bull ldquoThere is currently no good evidence for the role of any individual surgical intervention for the management of atelectasis of the tympanic membranerdquo
BUT
bull One Year Follow up only
bull No mention of attic retraction even though one paper only concerned this
Pars Tensa retractions - Natural History
bull TARGET trial ndash MISLEADING bull Retractions are spontaneously variable with time and may be reversible
bull Postero-superior retractions lead to 1o acquired
cholesteatomas (Sudhoff HolgerTos Mirko Pathogenesis of Attic Cholesteatoma Clinical
and Immunohistochemical Support for Combination of Retraction Theory and Proliferation Theory American Journal of Otology 2000 21(6)786-792)
Examples Pars Tensa retractions
Pars tensa retraction - What are you going to do
What are you going to do
How do you know if this retraction is going to progress
Grommets for Pars tensa retraction Pockets if under 10 and
bull Stage 1 and hearing loss from OME
bull Stage 2 and hearing loss or GENUINE erosion of LPI noted
bull Stage 3 with HL
bull Atelectasis Stage 4
Strategy for Pars Tensa Retractions
bull Use otoendoscope if limit not seen
bull Younger child ndash Repeated Ventilation tubes of hearing loss
bull Older child ndash consider excision amp grafting
bull Always montior the ME pressure -ve = delay surgery
bull Progressive or unstable poster-superior retraction - Operate
bull If hearing loss ndash offer surgery
bull Decision also depends on status of contralat ear age of patient amp historic
rate of progression
Reconstructive surgery for P tensa retraction if
bull Grade III retraction when adolescent
bull Retraction limits not seen in facial recess sinus tympani and unstable ndash periodic infections
bull Retraction into facial recess sinus tympani amp tympanogram improving
bull Grade IV retraction when adolescent
Mild retractionGood hearing
Pars tensa retraction pocket Atelectasiscollapse
Deep retractionEarly LPI erosion
Good or bad hearing
grommets
Glue earHearing loss
Trial grommets
Unstable retractionLimit of pocket out of view
Ossicular erosion
Reinforcement tympanoplasty+- ossiculoplasty
+- long term ventilation tube
Observation extrudes
Resolved discharge patient
lt10 years gt10 years
Failure
Summary
bull Classifications described
bull Vent Tubes correct Ptensa retractn while in situ
bull Postero-superior pockets can erode ossicles amp develop cholesteatoma
bull Surgery can be preventative or corrective
bull Operate if poor hearing or progression over time
bull Balance risks of surgery vs risks of non-intervention
bull Cartilage repair has gained popularity
Perforations
Safe vs Unsafe ears
bull Brain abscess
After cholesteatoma in 46
After mucosal disease in 38
After mod Rad mastoidectomy in 15
Browning GG The Unsafeness of safe ears JLO 1984a 9823-26
Aetiologies of TM Perforations
bull AOM perforation bull Otitis Externa ndash myringitis (fungal) bull CSOM bull Specific Chronic Suppurative Otitis Media TB Actinomyces Syphilis
bull Direct trauma to membrane bull Post ventilation tubes (275 ear 46 child 13 t-tubes)
bull Barotraumatic bull Blast Injury beware implantation
cholesteatoma
Size Matters
bull Conductive Hearing Loss variable 0 ndash 50 dB
bull Larger perforation = larger ABG
bull Low frequencies greatest affected
bull Post frac12 TM ndash transmits low frequency
bull Ant frac12 TM transmits high frequency
Management of TM perforations
bull Conservative ldquoA small perforation is good it acts as a natural ventilation
tuberdquo
Small hole no infections good hearing poor ETD = leave alone
bull Surgical ldquoThe perforation is bad it leads to recurrent ear infections
and restricts water sportsrdquo
Recurrent infections hearing loss other ear good = repair
Management of TM perforations
bull Conservative
bull Swabs + microsuction
bull Keep ear dry (earplugs for swimming)
bull Topical Agents - Ofloxacin or Ciprofloxacin drops + steroids
bull Systemic antibiotics
Management of TM perforations
bull Surgical
ndash Myringoplasty Tympanoplasty
ndash + - Adenoidectomy
Indications for repair of perforation
bull Any Ear with cholesteatoma
bull Not healed spontaneously after 6 months observation
andhellip
bull Recurrent otorrhoea
bull Disabling conductive hearing loss bull Bilateral ( gt30 - 40 dB)
bull Unilateral
bull To allow watersports
Wullstein Classification of Tympanoplasty (1956)
bull Type I ndash Myringoplasty = 3 ossicles present amp drum repair
bull Type II ndash Malleusincus eroded ndash reconstruction preserves middle ear depth
bull Type III ndash Lateral ossicles gone graft onto stapes superstructure columella effect shallow ME cleft
bull Type IV ndash No ossicles graft onto footplate
bull Type V ndash graft onto fixed footplate Va = fenestration of LSSC
Tympoanoplasty Type 1 in children ndash an evaluative study
bull Gautam Bir Sing et al Int J Ped Otorninolaryngol 200569 (8)1071-76
bull 80 graft success rate at 6 month
bull 61 significant improved hearing
Meta-analysis of Pediatric Tympanoplasty
bull Vrabec et al Arch Otolaryngol H amp Neck Surg 1999 125 (5) 530-34
bull Graft take rate 80 in perf less than half TM
69 if over half TM
bull Take rate with good vs poor ET function 87 cf 77
bull Adenoids ndash no difference
bull Normal contralat ear vs abnormal 80 cf 71
bull Wet ear ndash no difference
bull Increased success rate with increasing Age (p =0005)
What Age to perform myringoplasty
bull Success rate not influenced by age (eg House Ear Institute
Chandrasekhar et al Arch Oto HampN Surg 1995 121873-878 and Denoyelle Garabedien group Paris Laryngoscope)
bull Mean age of most paediatric published series = 10 ndash 11 years (range 4 ndash 17)
bull General Advice (GMorrison) ndash Other ear predicts outcome ndash 7 ndash 8 yrs or over if infections controllable and one good
hearing ear ndash As early as 3 ndash 4 if bilat Subtotal perfs with disabling
hearing loss amp infections
Myringoplasty ndash Personal Surgical tips
bull Consider periosteum graft
bull Dry graft thoroughly
bull Trim graft to exact size (little finger nail)
bull Underlay or reverse thru-lay technique
bull ldquoKerrrdquo ant wall pocket if no anterior lip
bull Subcuticular resorbable sutures
bull BIPP pack(s) except v young
EAM
ME
Anterior
Cartilage Tympanoplasty
bull Jansen 1958
bull Heerman 1962 ndash cartilage palisade
bull Techniques
ndash Island graft
ndash Palisades
ndash Butterfly inlay
ndash Cartilage Shield
Indications for Cartilage Tympanoplasty
bull Retraction pockets
bull Atelectasis
bull Poor ET Function
bull To prevent prosthesis extrusion
bull (Revision Surgery)
Reinforcement Tympanoplasty for retraction
Post Cartilage Tympanoplasty amp Incus transposition
Surgical Outcomes for Paediatric Myringoplasty
bull Fat plug Myringoplasty ndash 80 success bull Paper - steristrip myringoplasty ndash 65 bull Formal Myringoplasty - over 80 closure - 60 - 81 hearing
success bull Hearing gain - ABG to lt 10 dB to 23 lt20 dB in 883
Risk of OME after repair ndash 78 Long term graft breakdown ndash 65
Wet Ear Surgery
bull Moist ear ndash OK
bull Purulent Ear ndash Surgery Contraindicated
Conclusions
bull AOM and CSOM without cholesteatoma can lead to intracranial complications
bull Persistent perforations post grommets are seen in up to 46 patients
bull Operate when ET function improved
bull Cartilage Tympanoplasty has advantages in special cases
bull You can routinely repair ears at 8 years
bull Surgery best avoided in a purulent ear
Thank You
Erasmus Surgical Classification (Rotterdam)
bull I Atelectasis of TM
bull II Fixed to Promontory
bull III Fixed to IncusStapes
bull IV Deep pocket - limits not visible
bull V Deep pocket as IV with cholesteatoma
Management Options for Attic Retraction Pockets
bull Conservative ndash Observation amp serial audiometry +- CT scan
ndash Microsuction amp topical treatments
bull Surgical ndash ldquoOpenrdquo ndash atticotomy surgery
ndash ldquoClosedrdquo ndash Combined approach Tympano-mastoidectomy with attic reconstruction
Surgery for P flaccida retractions if
bull Limits not visible Type 3 4 amp hearing loss
ndash AND
bull Kertain build up
ndash OR
bull Intermittent scanty infections
Examples Attic retractions
What would you do
Stable vs Unstable
Stable = ldquoDryrdquo
bull Non-erosive non progressive
bull Not getting infections
bull No build up of keratin
CONSERVATIVE - IF GOOD HEARING
Unstable Attic Retraction
OPERATE
Pars Tensa Retractions
Pars Tensa Retractions
Dilemma
Early Surgery vs Late Surgery
Avoid ossicle erosion May get Hearing loss
Prevent Colesteatoma May get cholesteatoma
Can cause worse hearing
Management Options for Pars Tensa Retraction Pockets
bull Conservative ndash Observation amp serial audiometry +- CT
bull Surgical ndash Ventilation tube
ndash Excision of Pocket alone
ndash Excision of pocket with grafting
ndash Excision +- graft + Grommet
ndash Cartilage reinforcement tympanoplasty
Can the Literature give us the answers
helliphelliphelliphelliphelliphellip
Pars tensa Retractions in children by excision and ventilation tubes
bull Srinivasan V et al - Clin Otolaryngol Allied Sci 2000 25(4)253-6
bull 74 TM healing
bull 22 Re-retraction
Cochrane Review ndash Surgery for Tympanic Membrane Retraction Pockets
bull Nankivell PC and Pothier DD
bull 2010
bull 42 studies ndash 2 RCTs
bull Barbara 2008 (attic reconstruction) amp Elsheikh 2006 (pars tensa repair + - T tube)
bull ldquoNo statistical benefit of surgical interventionrdquo
bull ldquoThere is currently no good evidence for the role of any individual surgical intervention for the management of atelectasis of the tympanic membranerdquo
BUT
bull One Year Follow up only
bull No mention of attic retraction even though one paper only concerned this
Pars Tensa retractions - Natural History
bull TARGET trial ndash MISLEADING bull Retractions are spontaneously variable with time and may be reversible
bull Postero-superior retractions lead to 1o acquired
cholesteatomas (Sudhoff HolgerTos Mirko Pathogenesis of Attic Cholesteatoma Clinical
and Immunohistochemical Support for Combination of Retraction Theory and Proliferation Theory American Journal of Otology 2000 21(6)786-792)
Examples Pars Tensa retractions
Pars tensa retraction - What are you going to do
What are you going to do
How do you know if this retraction is going to progress
Grommets for Pars tensa retraction Pockets if under 10 and
bull Stage 1 and hearing loss from OME
bull Stage 2 and hearing loss or GENUINE erosion of LPI noted
bull Stage 3 with HL
bull Atelectasis Stage 4
Strategy for Pars Tensa Retractions
bull Use otoendoscope if limit not seen
bull Younger child ndash Repeated Ventilation tubes of hearing loss
bull Older child ndash consider excision amp grafting
bull Always montior the ME pressure -ve = delay surgery
bull Progressive or unstable poster-superior retraction - Operate
bull If hearing loss ndash offer surgery
bull Decision also depends on status of contralat ear age of patient amp historic
rate of progression
Reconstructive surgery for P tensa retraction if
bull Grade III retraction when adolescent
bull Retraction limits not seen in facial recess sinus tympani and unstable ndash periodic infections
bull Retraction into facial recess sinus tympani amp tympanogram improving
bull Grade IV retraction when adolescent
Mild retractionGood hearing
Pars tensa retraction pocket Atelectasiscollapse
Deep retractionEarly LPI erosion
Good or bad hearing
grommets
Glue earHearing loss
Trial grommets
Unstable retractionLimit of pocket out of view
Ossicular erosion
Reinforcement tympanoplasty+- ossiculoplasty
+- long term ventilation tube
Observation extrudes
Resolved discharge patient
lt10 years gt10 years
Failure
Summary
bull Classifications described
bull Vent Tubes correct Ptensa retractn while in situ
bull Postero-superior pockets can erode ossicles amp develop cholesteatoma
bull Surgery can be preventative or corrective
bull Operate if poor hearing or progression over time
bull Balance risks of surgery vs risks of non-intervention
bull Cartilage repair has gained popularity
Perforations
Safe vs Unsafe ears
bull Brain abscess
After cholesteatoma in 46
After mucosal disease in 38
After mod Rad mastoidectomy in 15
Browning GG The Unsafeness of safe ears JLO 1984a 9823-26
Aetiologies of TM Perforations
bull AOM perforation bull Otitis Externa ndash myringitis (fungal) bull CSOM bull Specific Chronic Suppurative Otitis Media TB Actinomyces Syphilis
bull Direct trauma to membrane bull Post ventilation tubes (275 ear 46 child 13 t-tubes)
bull Barotraumatic bull Blast Injury beware implantation
cholesteatoma
Size Matters
bull Conductive Hearing Loss variable 0 ndash 50 dB
bull Larger perforation = larger ABG
bull Low frequencies greatest affected
bull Post frac12 TM ndash transmits low frequency
bull Ant frac12 TM transmits high frequency
Management of TM perforations
bull Conservative ldquoA small perforation is good it acts as a natural ventilation
tuberdquo
Small hole no infections good hearing poor ETD = leave alone
bull Surgical ldquoThe perforation is bad it leads to recurrent ear infections
and restricts water sportsrdquo
Recurrent infections hearing loss other ear good = repair
Management of TM perforations
bull Conservative
bull Swabs + microsuction
bull Keep ear dry (earplugs for swimming)
bull Topical Agents - Ofloxacin or Ciprofloxacin drops + steroids
bull Systemic antibiotics
Management of TM perforations
bull Surgical
ndash Myringoplasty Tympanoplasty
ndash + - Adenoidectomy
Indications for repair of perforation
bull Any Ear with cholesteatoma
bull Not healed spontaneously after 6 months observation
andhellip
bull Recurrent otorrhoea
bull Disabling conductive hearing loss bull Bilateral ( gt30 - 40 dB)
bull Unilateral
bull To allow watersports
Wullstein Classification of Tympanoplasty (1956)
bull Type I ndash Myringoplasty = 3 ossicles present amp drum repair
bull Type II ndash Malleusincus eroded ndash reconstruction preserves middle ear depth
bull Type III ndash Lateral ossicles gone graft onto stapes superstructure columella effect shallow ME cleft
bull Type IV ndash No ossicles graft onto footplate
bull Type V ndash graft onto fixed footplate Va = fenestration of LSSC
Tympoanoplasty Type 1 in children ndash an evaluative study
bull Gautam Bir Sing et al Int J Ped Otorninolaryngol 200569 (8)1071-76
bull 80 graft success rate at 6 month
bull 61 significant improved hearing
Meta-analysis of Pediatric Tympanoplasty
bull Vrabec et al Arch Otolaryngol H amp Neck Surg 1999 125 (5) 530-34
bull Graft take rate 80 in perf less than half TM
69 if over half TM
bull Take rate with good vs poor ET function 87 cf 77
bull Adenoids ndash no difference
bull Normal contralat ear vs abnormal 80 cf 71
bull Wet ear ndash no difference
bull Increased success rate with increasing Age (p =0005)
What Age to perform myringoplasty
bull Success rate not influenced by age (eg House Ear Institute
Chandrasekhar et al Arch Oto HampN Surg 1995 121873-878 and Denoyelle Garabedien group Paris Laryngoscope)
bull Mean age of most paediatric published series = 10 ndash 11 years (range 4 ndash 17)
bull General Advice (GMorrison) ndash Other ear predicts outcome ndash 7 ndash 8 yrs or over if infections controllable and one good
hearing ear ndash As early as 3 ndash 4 if bilat Subtotal perfs with disabling
hearing loss amp infections
Myringoplasty ndash Personal Surgical tips
bull Consider periosteum graft
bull Dry graft thoroughly
bull Trim graft to exact size (little finger nail)
bull Underlay or reverse thru-lay technique
bull ldquoKerrrdquo ant wall pocket if no anterior lip
bull Subcuticular resorbable sutures
bull BIPP pack(s) except v young
EAM
ME
Anterior
Cartilage Tympanoplasty
bull Jansen 1958
bull Heerman 1962 ndash cartilage palisade
bull Techniques
ndash Island graft
ndash Palisades
ndash Butterfly inlay
ndash Cartilage Shield
Indications for Cartilage Tympanoplasty
bull Retraction pockets
bull Atelectasis
bull Poor ET Function
bull To prevent prosthesis extrusion
bull (Revision Surgery)
Reinforcement Tympanoplasty for retraction
Post Cartilage Tympanoplasty amp Incus transposition
Surgical Outcomes for Paediatric Myringoplasty
bull Fat plug Myringoplasty ndash 80 success bull Paper - steristrip myringoplasty ndash 65 bull Formal Myringoplasty - over 80 closure - 60 - 81 hearing
success bull Hearing gain - ABG to lt 10 dB to 23 lt20 dB in 883
Risk of OME after repair ndash 78 Long term graft breakdown ndash 65
Wet Ear Surgery
bull Moist ear ndash OK
bull Purulent Ear ndash Surgery Contraindicated
Conclusions
bull AOM and CSOM without cholesteatoma can lead to intracranial complications
bull Persistent perforations post grommets are seen in up to 46 patients
bull Operate when ET function improved
bull Cartilage Tympanoplasty has advantages in special cases
bull You can routinely repair ears at 8 years
bull Surgery best avoided in a purulent ear
Thank You
Management Options for Attic Retraction Pockets
bull Conservative ndash Observation amp serial audiometry +- CT scan
ndash Microsuction amp topical treatments
bull Surgical ndash ldquoOpenrdquo ndash atticotomy surgery
ndash ldquoClosedrdquo ndash Combined approach Tympano-mastoidectomy with attic reconstruction
Surgery for P flaccida retractions if
bull Limits not visible Type 3 4 amp hearing loss
ndash AND
bull Kertain build up
ndash OR
bull Intermittent scanty infections
Examples Attic retractions
What would you do
Stable vs Unstable
Stable = ldquoDryrdquo
bull Non-erosive non progressive
bull Not getting infections
bull No build up of keratin
CONSERVATIVE - IF GOOD HEARING
Unstable Attic Retraction
OPERATE
Pars Tensa Retractions
Pars Tensa Retractions
Dilemma
Early Surgery vs Late Surgery
Avoid ossicle erosion May get Hearing loss
Prevent Colesteatoma May get cholesteatoma
Can cause worse hearing
Management Options for Pars Tensa Retraction Pockets
bull Conservative ndash Observation amp serial audiometry +- CT
bull Surgical ndash Ventilation tube
ndash Excision of Pocket alone
ndash Excision of pocket with grafting
ndash Excision +- graft + Grommet
ndash Cartilage reinforcement tympanoplasty
Can the Literature give us the answers
helliphelliphelliphelliphelliphellip
Pars tensa Retractions in children by excision and ventilation tubes
bull Srinivasan V et al - Clin Otolaryngol Allied Sci 2000 25(4)253-6
bull 74 TM healing
bull 22 Re-retraction
Cochrane Review ndash Surgery for Tympanic Membrane Retraction Pockets
bull Nankivell PC and Pothier DD
bull 2010
bull 42 studies ndash 2 RCTs
bull Barbara 2008 (attic reconstruction) amp Elsheikh 2006 (pars tensa repair + - T tube)
bull ldquoNo statistical benefit of surgical interventionrdquo
bull ldquoThere is currently no good evidence for the role of any individual surgical intervention for the management of atelectasis of the tympanic membranerdquo
BUT
bull One Year Follow up only
bull No mention of attic retraction even though one paper only concerned this
Pars Tensa retractions - Natural History
bull TARGET trial ndash MISLEADING bull Retractions are spontaneously variable with time and may be reversible
bull Postero-superior retractions lead to 1o acquired
cholesteatomas (Sudhoff HolgerTos Mirko Pathogenesis of Attic Cholesteatoma Clinical
and Immunohistochemical Support for Combination of Retraction Theory and Proliferation Theory American Journal of Otology 2000 21(6)786-792)
Examples Pars Tensa retractions
Pars tensa retraction - What are you going to do
What are you going to do
How do you know if this retraction is going to progress
Grommets for Pars tensa retraction Pockets if under 10 and
bull Stage 1 and hearing loss from OME
bull Stage 2 and hearing loss or GENUINE erosion of LPI noted
bull Stage 3 with HL
bull Atelectasis Stage 4
Strategy for Pars Tensa Retractions
bull Use otoendoscope if limit not seen
bull Younger child ndash Repeated Ventilation tubes of hearing loss
bull Older child ndash consider excision amp grafting
bull Always montior the ME pressure -ve = delay surgery
bull Progressive or unstable poster-superior retraction - Operate
bull If hearing loss ndash offer surgery
bull Decision also depends on status of contralat ear age of patient amp historic
rate of progression
Reconstructive surgery for P tensa retraction if
bull Grade III retraction when adolescent
bull Retraction limits not seen in facial recess sinus tympani and unstable ndash periodic infections
bull Retraction into facial recess sinus tympani amp tympanogram improving
bull Grade IV retraction when adolescent
Mild retractionGood hearing
Pars tensa retraction pocket Atelectasiscollapse
Deep retractionEarly LPI erosion
Good or bad hearing
grommets
Glue earHearing loss
Trial grommets
Unstable retractionLimit of pocket out of view
Ossicular erosion
Reinforcement tympanoplasty+- ossiculoplasty
+- long term ventilation tube
Observation extrudes
Resolved discharge patient
lt10 years gt10 years
Failure
Summary
bull Classifications described
bull Vent Tubes correct Ptensa retractn while in situ
bull Postero-superior pockets can erode ossicles amp develop cholesteatoma
bull Surgery can be preventative or corrective
bull Operate if poor hearing or progression over time
bull Balance risks of surgery vs risks of non-intervention
bull Cartilage repair has gained popularity
Perforations
Safe vs Unsafe ears
bull Brain abscess
After cholesteatoma in 46
After mucosal disease in 38
After mod Rad mastoidectomy in 15
Browning GG The Unsafeness of safe ears JLO 1984a 9823-26
Aetiologies of TM Perforations
bull AOM perforation bull Otitis Externa ndash myringitis (fungal) bull CSOM bull Specific Chronic Suppurative Otitis Media TB Actinomyces Syphilis
bull Direct trauma to membrane bull Post ventilation tubes (275 ear 46 child 13 t-tubes)
bull Barotraumatic bull Blast Injury beware implantation
cholesteatoma
Size Matters
bull Conductive Hearing Loss variable 0 ndash 50 dB
bull Larger perforation = larger ABG
bull Low frequencies greatest affected
bull Post frac12 TM ndash transmits low frequency
bull Ant frac12 TM transmits high frequency
Management of TM perforations
bull Conservative ldquoA small perforation is good it acts as a natural ventilation
tuberdquo
Small hole no infections good hearing poor ETD = leave alone
bull Surgical ldquoThe perforation is bad it leads to recurrent ear infections
and restricts water sportsrdquo
Recurrent infections hearing loss other ear good = repair
Management of TM perforations
bull Conservative
bull Swabs + microsuction
bull Keep ear dry (earplugs for swimming)
bull Topical Agents - Ofloxacin or Ciprofloxacin drops + steroids
bull Systemic antibiotics
Management of TM perforations
bull Surgical
ndash Myringoplasty Tympanoplasty
ndash + - Adenoidectomy
Indications for repair of perforation
bull Any Ear with cholesteatoma
bull Not healed spontaneously after 6 months observation
andhellip
bull Recurrent otorrhoea
bull Disabling conductive hearing loss bull Bilateral ( gt30 - 40 dB)
bull Unilateral
bull To allow watersports
Wullstein Classification of Tympanoplasty (1956)
bull Type I ndash Myringoplasty = 3 ossicles present amp drum repair
bull Type II ndash Malleusincus eroded ndash reconstruction preserves middle ear depth
bull Type III ndash Lateral ossicles gone graft onto stapes superstructure columella effect shallow ME cleft
bull Type IV ndash No ossicles graft onto footplate
bull Type V ndash graft onto fixed footplate Va = fenestration of LSSC
Tympoanoplasty Type 1 in children ndash an evaluative study
bull Gautam Bir Sing et al Int J Ped Otorninolaryngol 200569 (8)1071-76
bull 80 graft success rate at 6 month
bull 61 significant improved hearing
Meta-analysis of Pediatric Tympanoplasty
bull Vrabec et al Arch Otolaryngol H amp Neck Surg 1999 125 (5) 530-34
bull Graft take rate 80 in perf less than half TM
69 if over half TM
bull Take rate with good vs poor ET function 87 cf 77
bull Adenoids ndash no difference
bull Normal contralat ear vs abnormal 80 cf 71
bull Wet ear ndash no difference
bull Increased success rate with increasing Age (p =0005)
What Age to perform myringoplasty
bull Success rate not influenced by age (eg House Ear Institute
Chandrasekhar et al Arch Oto HampN Surg 1995 121873-878 and Denoyelle Garabedien group Paris Laryngoscope)
bull Mean age of most paediatric published series = 10 ndash 11 years (range 4 ndash 17)
bull General Advice (GMorrison) ndash Other ear predicts outcome ndash 7 ndash 8 yrs or over if infections controllable and one good
hearing ear ndash As early as 3 ndash 4 if bilat Subtotal perfs with disabling
hearing loss amp infections
Myringoplasty ndash Personal Surgical tips
bull Consider periosteum graft
bull Dry graft thoroughly
bull Trim graft to exact size (little finger nail)
bull Underlay or reverse thru-lay technique
bull ldquoKerrrdquo ant wall pocket if no anterior lip
bull Subcuticular resorbable sutures
bull BIPP pack(s) except v young
EAM
ME
Anterior
Cartilage Tympanoplasty
bull Jansen 1958
bull Heerman 1962 ndash cartilage palisade
bull Techniques
ndash Island graft
ndash Palisades
ndash Butterfly inlay
ndash Cartilage Shield
Indications for Cartilage Tympanoplasty
bull Retraction pockets
bull Atelectasis
bull Poor ET Function
bull To prevent prosthesis extrusion
bull (Revision Surgery)
Reinforcement Tympanoplasty for retraction
Post Cartilage Tympanoplasty amp Incus transposition
Surgical Outcomes for Paediatric Myringoplasty
bull Fat plug Myringoplasty ndash 80 success bull Paper - steristrip myringoplasty ndash 65 bull Formal Myringoplasty - over 80 closure - 60 - 81 hearing
success bull Hearing gain - ABG to lt 10 dB to 23 lt20 dB in 883
Risk of OME after repair ndash 78 Long term graft breakdown ndash 65
Wet Ear Surgery
bull Moist ear ndash OK
bull Purulent Ear ndash Surgery Contraindicated
Conclusions
bull AOM and CSOM without cholesteatoma can lead to intracranial complications
bull Persistent perforations post grommets are seen in up to 46 patients
bull Operate when ET function improved
bull Cartilage Tympanoplasty has advantages in special cases
bull You can routinely repair ears at 8 years
bull Surgery best avoided in a purulent ear
Thank You
Surgery for P flaccida retractions if
bull Limits not visible Type 3 4 amp hearing loss
ndash AND
bull Kertain build up
ndash OR
bull Intermittent scanty infections
Examples Attic retractions
What would you do
Stable vs Unstable
Stable = ldquoDryrdquo
bull Non-erosive non progressive
bull Not getting infections
bull No build up of keratin
CONSERVATIVE - IF GOOD HEARING
Unstable Attic Retraction
OPERATE
Pars Tensa Retractions
Pars Tensa Retractions
Dilemma
Early Surgery vs Late Surgery
Avoid ossicle erosion May get Hearing loss
Prevent Colesteatoma May get cholesteatoma
Can cause worse hearing
Management Options for Pars Tensa Retraction Pockets
bull Conservative ndash Observation amp serial audiometry +- CT
bull Surgical ndash Ventilation tube
ndash Excision of Pocket alone
ndash Excision of pocket with grafting
ndash Excision +- graft + Grommet
ndash Cartilage reinforcement tympanoplasty
Can the Literature give us the answers
helliphelliphelliphelliphelliphellip
Pars tensa Retractions in children by excision and ventilation tubes
bull Srinivasan V et al - Clin Otolaryngol Allied Sci 2000 25(4)253-6
bull 74 TM healing
bull 22 Re-retraction
Cochrane Review ndash Surgery for Tympanic Membrane Retraction Pockets
bull Nankivell PC and Pothier DD
bull 2010
bull 42 studies ndash 2 RCTs
bull Barbara 2008 (attic reconstruction) amp Elsheikh 2006 (pars tensa repair + - T tube)
bull ldquoNo statistical benefit of surgical interventionrdquo
bull ldquoThere is currently no good evidence for the role of any individual surgical intervention for the management of atelectasis of the tympanic membranerdquo
BUT
bull One Year Follow up only
bull No mention of attic retraction even though one paper only concerned this
Pars Tensa retractions - Natural History
bull TARGET trial ndash MISLEADING bull Retractions are spontaneously variable with time and may be reversible
bull Postero-superior retractions lead to 1o acquired
cholesteatomas (Sudhoff HolgerTos Mirko Pathogenesis of Attic Cholesteatoma Clinical
and Immunohistochemical Support for Combination of Retraction Theory and Proliferation Theory American Journal of Otology 2000 21(6)786-792)
Examples Pars Tensa retractions
Pars tensa retraction - What are you going to do
What are you going to do
How do you know if this retraction is going to progress
Grommets for Pars tensa retraction Pockets if under 10 and
bull Stage 1 and hearing loss from OME
bull Stage 2 and hearing loss or GENUINE erosion of LPI noted
bull Stage 3 with HL
bull Atelectasis Stage 4
Strategy for Pars Tensa Retractions
bull Use otoendoscope if limit not seen
bull Younger child ndash Repeated Ventilation tubes of hearing loss
bull Older child ndash consider excision amp grafting
bull Always montior the ME pressure -ve = delay surgery
bull Progressive or unstable poster-superior retraction - Operate
bull If hearing loss ndash offer surgery
bull Decision also depends on status of contralat ear age of patient amp historic
rate of progression
Reconstructive surgery for P tensa retraction if
bull Grade III retraction when adolescent
bull Retraction limits not seen in facial recess sinus tympani and unstable ndash periodic infections
bull Retraction into facial recess sinus tympani amp tympanogram improving
bull Grade IV retraction when adolescent
Mild retractionGood hearing
Pars tensa retraction pocket Atelectasiscollapse
Deep retractionEarly LPI erosion
Good or bad hearing
grommets
Glue earHearing loss
Trial grommets
Unstable retractionLimit of pocket out of view
Ossicular erosion
Reinforcement tympanoplasty+- ossiculoplasty
+- long term ventilation tube
Observation extrudes
Resolved discharge patient
lt10 years gt10 years
Failure
Summary
bull Classifications described
bull Vent Tubes correct Ptensa retractn while in situ
bull Postero-superior pockets can erode ossicles amp develop cholesteatoma
bull Surgery can be preventative or corrective
bull Operate if poor hearing or progression over time
bull Balance risks of surgery vs risks of non-intervention
bull Cartilage repair has gained popularity
Perforations
Safe vs Unsafe ears
bull Brain abscess
After cholesteatoma in 46
After mucosal disease in 38
After mod Rad mastoidectomy in 15
Browning GG The Unsafeness of safe ears JLO 1984a 9823-26
Aetiologies of TM Perforations
bull AOM perforation bull Otitis Externa ndash myringitis (fungal) bull CSOM bull Specific Chronic Suppurative Otitis Media TB Actinomyces Syphilis
bull Direct trauma to membrane bull Post ventilation tubes (275 ear 46 child 13 t-tubes)
bull Barotraumatic bull Blast Injury beware implantation
cholesteatoma
Size Matters
bull Conductive Hearing Loss variable 0 ndash 50 dB
bull Larger perforation = larger ABG
bull Low frequencies greatest affected
bull Post frac12 TM ndash transmits low frequency
bull Ant frac12 TM transmits high frequency
Management of TM perforations
bull Conservative ldquoA small perforation is good it acts as a natural ventilation
tuberdquo
Small hole no infections good hearing poor ETD = leave alone
bull Surgical ldquoThe perforation is bad it leads to recurrent ear infections
and restricts water sportsrdquo
Recurrent infections hearing loss other ear good = repair
Management of TM perforations
bull Conservative
bull Swabs + microsuction
bull Keep ear dry (earplugs for swimming)
bull Topical Agents - Ofloxacin or Ciprofloxacin drops + steroids
bull Systemic antibiotics
Management of TM perforations
bull Surgical
ndash Myringoplasty Tympanoplasty
ndash + - Adenoidectomy
Indications for repair of perforation
bull Any Ear with cholesteatoma
bull Not healed spontaneously after 6 months observation
andhellip
bull Recurrent otorrhoea
bull Disabling conductive hearing loss bull Bilateral ( gt30 - 40 dB)
bull Unilateral
bull To allow watersports
Wullstein Classification of Tympanoplasty (1956)
bull Type I ndash Myringoplasty = 3 ossicles present amp drum repair
bull Type II ndash Malleusincus eroded ndash reconstruction preserves middle ear depth
bull Type III ndash Lateral ossicles gone graft onto stapes superstructure columella effect shallow ME cleft
bull Type IV ndash No ossicles graft onto footplate
bull Type V ndash graft onto fixed footplate Va = fenestration of LSSC
Tympoanoplasty Type 1 in children ndash an evaluative study
bull Gautam Bir Sing et al Int J Ped Otorninolaryngol 200569 (8)1071-76
bull 80 graft success rate at 6 month
bull 61 significant improved hearing
Meta-analysis of Pediatric Tympanoplasty
bull Vrabec et al Arch Otolaryngol H amp Neck Surg 1999 125 (5) 530-34
bull Graft take rate 80 in perf less than half TM
69 if over half TM
bull Take rate with good vs poor ET function 87 cf 77
bull Adenoids ndash no difference
bull Normal contralat ear vs abnormal 80 cf 71
bull Wet ear ndash no difference
bull Increased success rate with increasing Age (p =0005)
What Age to perform myringoplasty
bull Success rate not influenced by age (eg House Ear Institute
Chandrasekhar et al Arch Oto HampN Surg 1995 121873-878 and Denoyelle Garabedien group Paris Laryngoscope)
bull Mean age of most paediatric published series = 10 ndash 11 years (range 4 ndash 17)
bull General Advice (GMorrison) ndash Other ear predicts outcome ndash 7 ndash 8 yrs or over if infections controllable and one good
hearing ear ndash As early as 3 ndash 4 if bilat Subtotal perfs with disabling
hearing loss amp infections
Myringoplasty ndash Personal Surgical tips
bull Consider periosteum graft
bull Dry graft thoroughly
bull Trim graft to exact size (little finger nail)
bull Underlay or reverse thru-lay technique
bull ldquoKerrrdquo ant wall pocket if no anterior lip
bull Subcuticular resorbable sutures
bull BIPP pack(s) except v young
EAM
ME
Anterior
Cartilage Tympanoplasty
bull Jansen 1958
bull Heerman 1962 ndash cartilage palisade
bull Techniques
ndash Island graft
ndash Palisades
ndash Butterfly inlay
ndash Cartilage Shield
Indications for Cartilage Tympanoplasty
bull Retraction pockets
bull Atelectasis
bull Poor ET Function
bull To prevent prosthesis extrusion
bull (Revision Surgery)
Reinforcement Tympanoplasty for retraction
Post Cartilage Tympanoplasty amp Incus transposition
Surgical Outcomes for Paediatric Myringoplasty
bull Fat plug Myringoplasty ndash 80 success bull Paper - steristrip myringoplasty ndash 65 bull Formal Myringoplasty - over 80 closure - 60 - 81 hearing
success bull Hearing gain - ABG to lt 10 dB to 23 lt20 dB in 883
Risk of OME after repair ndash 78 Long term graft breakdown ndash 65
Wet Ear Surgery
bull Moist ear ndash OK
bull Purulent Ear ndash Surgery Contraindicated
Conclusions
bull AOM and CSOM without cholesteatoma can lead to intracranial complications
bull Persistent perforations post grommets are seen in up to 46 patients
bull Operate when ET function improved
bull Cartilage Tympanoplasty has advantages in special cases
bull You can routinely repair ears at 8 years
bull Surgery best avoided in a purulent ear
Thank You
Examples Attic retractions
What would you do
Stable vs Unstable
Stable = ldquoDryrdquo
bull Non-erosive non progressive
bull Not getting infections
bull No build up of keratin
CONSERVATIVE - IF GOOD HEARING
Unstable Attic Retraction
OPERATE
Pars Tensa Retractions
Pars Tensa Retractions
Dilemma
Early Surgery vs Late Surgery
Avoid ossicle erosion May get Hearing loss
Prevent Colesteatoma May get cholesteatoma
Can cause worse hearing
Management Options for Pars Tensa Retraction Pockets
bull Conservative ndash Observation amp serial audiometry +- CT
bull Surgical ndash Ventilation tube
ndash Excision of Pocket alone
ndash Excision of pocket with grafting
ndash Excision +- graft + Grommet
ndash Cartilage reinforcement tympanoplasty
Can the Literature give us the answers
helliphelliphelliphelliphelliphellip
Pars tensa Retractions in children by excision and ventilation tubes
bull Srinivasan V et al - Clin Otolaryngol Allied Sci 2000 25(4)253-6
bull 74 TM healing
bull 22 Re-retraction
Cochrane Review ndash Surgery for Tympanic Membrane Retraction Pockets
bull Nankivell PC and Pothier DD
bull 2010
bull 42 studies ndash 2 RCTs
bull Barbara 2008 (attic reconstruction) amp Elsheikh 2006 (pars tensa repair + - T tube)
bull ldquoNo statistical benefit of surgical interventionrdquo
bull ldquoThere is currently no good evidence for the role of any individual surgical intervention for the management of atelectasis of the tympanic membranerdquo
BUT
bull One Year Follow up only
bull No mention of attic retraction even though one paper only concerned this
Pars Tensa retractions - Natural History
bull TARGET trial ndash MISLEADING bull Retractions are spontaneously variable with time and may be reversible
bull Postero-superior retractions lead to 1o acquired
cholesteatomas (Sudhoff HolgerTos Mirko Pathogenesis of Attic Cholesteatoma Clinical
and Immunohistochemical Support for Combination of Retraction Theory and Proliferation Theory American Journal of Otology 2000 21(6)786-792)
Examples Pars Tensa retractions
Pars tensa retraction - What are you going to do
What are you going to do
How do you know if this retraction is going to progress
Grommets for Pars tensa retraction Pockets if under 10 and
bull Stage 1 and hearing loss from OME
bull Stage 2 and hearing loss or GENUINE erosion of LPI noted
bull Stage 3 with HL
bull Atelectasis Stage 4
Strategy for Pars Tensa Retractions
bull Use otoendoscope if limit not seen
bull Younger child ndash Repeated Ventilation tubes of hearing loss
bull Older child ndash consider excision amp grafting
bull Always montior the ME pressure -ve = delay surgery
bull Progressive or unstable poster-superior retraction - Operate
bull If hearing loss ndash offer surgery
bull Decision also depends on status of contralat ear age of patient amp historic
rate of progression
Reconstructive surgery for P tensa retraction if
bull Grade III retraction when adolescent
bull Retraction limits not seen in facial recess sinus tympani and unstable ndash periodic infections
bull Retraction into facial recess sinus tympani amp tympanogram improving
bull Grade IV retraction when adolescent
Mild retractionGood hearing
Pars tensa retraction pocket Atelectasiscollapse
Deep retractionEarly LPI erosion
Good or bad hearing
grommets
Glue earHearing loss
Trial grommets
Unstable retractionLimit of pocket out of view
Ossicular erosion
Reinforcement tympanoplasty+- ossiculoplasty
+- long term ventilation tube
Observation extrudes
Resolved discharge patient
lt10 years gt10 years
Failure
Summary
bull Classifications described
bull Vent Tubes correct Ptensa retractn while in situ
bull Postero-superior pockets can erode ossicles amp develop cholesteatoma
bull Surgery can be preventative or corrective
bull Operate if poor hearing or progression over time
bull Balance risks of surgery vs risks of non-intervention
bull Cartilage repair has gained popularity
Perforations
Safe vs Unsafe ears
bull Brain abscess
After cholesteatoma in 46
After mucosal disease in 38
After mod Rad mastoidectomy in 15
Browning GG The Unsafeness of safe ears JLO 1984a 9823-26
Aetiologies of TM Perforations
bull AOM perforation bull Otitis Externa ndash myringitis (fungal) bull CSOM bull Specific Chronic Suppurative Otitis Media TB Actinomyces Syphilis
bull Direct trauma to membrane bull Post ventilation tubes (275 ear 46 child 13 t-tubes)
bull Barotraumatic bull Blast Injury beware implantation
cholesteatoma
Size Matters
bull Conductive Hearing Loss variable 0 ndash 50 dB
bull Larger perforation = larger ABG
bull Low frequencies greatest affected
bull Post frac12 TM ndash transmits low frequency
bull Ant frac12 TM transmits high frequency
Management of TM perforations
bull Conservative ldquoA small perforation is good it acts as a natural ventilation
tuberdquo
Small hole no infections good hearing poor ETD = leave alone
bull Surgical ldquoThe perforation is bad it leads to recurrent ear infections
and restricts water sportsrdquo
Recurrent infections hearing loss other ear good = repair
Management of TM perforations
bull Conservative
bull Swabs + microsuction
bull Keep ear dry (earplugs for swimming)
bull Topical Agents - Ofloxacin or Ciprofloxacin drops + steroids
bull Systemic antibiotics
Management of TM perforations
bull Surgical
ndash Myringoplasty Tympanoplasty
ndash + - Adenoidectomy
Indications for repair of perforation
bull Any Ear with cholesteatoma
bull Not healed spontaneously after 6 months observation
andhellip
bull Recurrent otorrhoea
bull Disabling conductive hearing loss bull Bilateral ( gt30 - 40 dB)
bull Unilateral
bull To allow watersports
Wullstein Classification of Tympanoplasty (1956)
bull Type I ndash Myringoplasty = 3 ossicles present amp drum repair
bull Type II ndash Malleusincus eroded ndash reconstruction preserves middle ear depth
bull Type III ndash Lateral ossicles gone graft onto stapes superstructure columella effect shallow ME cleft
bull Type IV ndash No ossicles graft onto footplate
bull Type V ndash graft onto fixed footplate Va = fenestration of LSSC
Tympoanoplasty Type 1 in children ndash an evaluative study
bull Gautam Bir Sing et al Int J Ped Otorninolaryngol 200569 (8)1071-76
bull 80 graft success rate at 6 month
bull 61 significant improved hearing
Meta-analysis of Pediatric Tympanoplasty
bull Vrabec et al Arch Otolaryngol H amp Neck Surg 1999 125 (5) 530-34
bull Graft take rate 80 in perf less than half TM
69 if over half TM
bull Take rate with good vs poor ET function 87 cf 77
bull Adenoids ndash no difference
bull Normal contralat ear vs abnormal 80 cf 71
bull Wet ear ndash no difference
bull Increased success rate with increasing Age (p =0005)
What Age to perform myringoplasty
bull Success rate not influenced by age (eg House Ear Institute
Chandrasekhar et al Arch Oto HampN Surg 1995 121873-878 and Denoyelle Garabedien group Paris Laryngoscope)
bull Mean age of most paediatric published series = 10 ndash 11 years (range 4 ndash 17)
bull General Advice (GMorrison) ndash Other ear predicts outcome ndash 7 ndash 8 yrs or over if infections controllable and one good
hearing ear ndash As early as 3 ndash 4 if bilat Subtotal perfs with disabling
hearing loss amp infections
Myringoplasty ndash Personal Surgical tips
bull Consider periosteum graft
bull Dry graft thoroughly
bull Trim graft to exact size (little finger nail)
bull Underlay or reverse thru-lay technique
bull ldquoKerrrdquo ant wall pocket if no anterior lip
bull Subcuticular resorbable sutures
bull BIPP pack(s) except v young
EAM
ME
Anterior
Cartilage Tympanoplasty
bull Jansen 1958
bull Heerman 1962 ndash cartilage palisade
bull Techniques
ndash Island graft
ndash Palisades
ndash Butterfly inlay
ndash Cartilage Shield
Indications for Cartilage Tympanoplasty
bull Retraction pockets
bull Atelectasis
bull Poor ET Function
bull To prevent prosthesis extrusion
bull (Revision Surgery)
Reinforcement Tympanoplasty for retraction
Post Cartilage Tympanoplasty amp Incus transposition
Surgical Outcomes for Paediatric Myringoplasty
bull Fat plug Myringoplasty ndash 80 success bull Paper - steristrip myringoplasty ndash 65 bull Formal Myringoplasty - over 80 closure - 60 - 81 hearing
success bull Hearing gain - ABG to lt 10 dB to 23 lt20 dB in 883
Risk of OME after repair ndash 78 Long term graft breakdown ndash 65
Wet Ear Surgery
bull Moist ear ndash OK
bull Purulent Ear ndash Surgery Contraindicated
Conclusions
bull AOM and CSOM without cholesteatoma can lead to intracranial complications
bull Persistent perforations post grommets are seen in up to 46 patients
bull Operate when ET function improved
bull Cartilage Tympanoplasty has advantages in special cases
bull You can routinely repair ears at 8 years
bull Surgery best avoided in a purulent ear
Thank You
What would you do
Stable vs Unstable
Stable = ldquoDryrdquo
bull Non-erosive non progressive
bull Not getting infections
bull No build up of keratin
CONSERVATIVE - IF GOOD HEARING
Unstable Attic Retraction
OPERATE
Pars Tensa Retractions
Pars Tensa Retractions
Dilemma
Early Surgery vs Late Surgery
Avoid ossicle erosion May get Hearing loss
Prevent Colesteatoma May get cholesteatoma
Can cause worse hearing
Management Options for Pars Tensa Retraction Pockets
bull Conservative ndash Observation amp serial audiometry +- CT
bull Surgical ndash Ventilation tube
ndash Excision of Pocket alone
ndash Excision of pocket with grafting
ndash Excision +- graft + Grommet
ndash Cartilage reinforcement tympanoplasty
Can the Literature give us the answers
helliphelliphelliphelliphelliphellip
Pars tensa Retractions in children by excision and ventilation tubes
bull Srinivasan V et al - Clin Otolaryngol Allied Sci 2000 25(4)253-6
bull 74 TM healing
bull 22 Re-retraction
Cochrane Review ndash Surgery for Tympanic Membrane Retraction Pockets
bull Nankivell PC and Pothier DD
bull 2010
bull 42 studies ndash 2 RCTs
bull Barbara 2008 (attic reconstruction) amp Elsheikh 2006 (pars tensa repair + - T tube)
bull ldquoNo statistical benefit of surgical interventionrdquo
bull ldquoThere is currently no good evidence for the role of any individual surgical intervention for the management of atelectasis of the tympanic membranerdquo
BUT
bull One Year Follow up only
bull No mention of attic retraction even though one paper only concerned this
Pars Tensa retractions - Natural History
bull TARGET trial ndash MISLEADING bull Retractions are spontaneously variable with time and may be reversible
bull Postero-superior retractions lead to 1o acquired
cholesteatomas (Sudhoff HolgerTos Mirko Pathogenesis of Attic Cholesteatoma Clinical
and Immunohistochemical Support for Combination of Retraction Theory and Proliferation Theory American Journal of Otology 2000 21(6)786-792)
Examples Pars Tensa retractions
Pars tensa retraction - What are you going to do
What are you going to do
How do you know if this retraction is going to progress
Grommets for Pars tensa retraction Pockets if under 10 and
bull Stage 1 and hearing loss from OME
bull Stage 2 and hearing loss or GENUINE erosion of LPI noted
bull Stage 3 with HL
bull Atelectasis Stage 4
Strategy for Pars Tensa Retractions
bull Use otoendoscope if limit not seen
bull Younger child ndash Repeated Ventilation tubes of hearing loss
bull Older child ndash consider excision amp grafting
bull Always montior the ME pressure -ve = delay surgery
bull Progressive or unstable poster-superior retraction - Operate
bull If hearing loss ndash offer surgery
bull Decision also depends on status of contralat ear age of patient amp historic
rate of progression
Reconstructive surgery for P tensa retraction if
bull Grade III retraction when adolescent
bull Retraction limits not seen in facial recess sinus tympani and unstable ndash periodic infections
bull Retraction into facial recess sinus tympani amp tympanogram improving
bull Grade IV retraction when adolescent
Mild retractionGood hearing
Pars tensa retraction pocket Atelectasiscollapse
Deep retractionEarly LPI erosion
Good or bad hearing
grommets
Glue earHearing loss
Trial grommets
Unstable retractionLimit of pocket out of view
Ossicular erosion
Reinforcement tympanoplasty+- ossiculoplasty
+- long term ventilation tube
Observation extrudes
Resolved discharge patient
lt10 years gt10 years
Failure
Summary
bull Classifications described
bull Vent Tubes correct Ptensa retractn while in situ
bull Postero-superior pockets can erode ossicles amp develop cholesteatoma
bull Surgery can be preventative or corrective
bull Operate if poor hearing or progression over time
bull Balance risks of surgery vs risks of non-intervention
bull Cartilage repair has gained popularity
Perforations
Safe vs Unsafe ears
bull Brain abscess
After cholesteatoma in 46
After mucosal disease in 38
After mod Rad mastoidectomy in 15
Browning GG The Unsafeness of safe ears JLO 1984a 9823-26
Aetiologies of TM Perforations
bull AOM perforation bull Otitis Externa ndash myringitis (fungal) bull CSOM bull Specific Chronic Suppurative Otitis Media TB Actinomyces Syphilis
bull Direct trauma to membrane bull Post ventilation tubes (275 ear 46 child 13 t-tubes)
bull Barotraumatic bull Blast Injury beware implantation
cholesteatoma
Size Matters
bull Conductive Hearing Loss variable 0 ndash 50 dB
bull Larger perforation = larger ABG
bull Low frequencies greatest affected
bull Post frac12 TM ndash transmits low frequency
bull Ant frac12 TM transmits high frequency
Management of TM perforations
bull Conservative ldquoA small perforation is good it acts as a natural ventilation
tuberdquo
Small hole no infections good hearing poor ETD = leave alone
bull Surgical ldquoThe perforation is bad it leads to recurrent ear infections
and restricts water sportsrdquo
Recurrent infections hearing loss other ear good = repair
Management of TM perforations
bull Conservative
bull Swabs + microsuction
bull Keep ear dry (earplugs for swimming)
bull Topical Agents - Ofloxacin or Ciprofloxacin drops + steroids
bull Systemic antibiotics
Management of TM perforations
bull Surgical
ndash Myringoplasty Tympanoplasty
ndash + - Adenoidectomy
Indications for repair of perforation
bull Any Ear with cholesteatoma
bull Not healed spontaneously after 6 months observation
andhellip
bull Recurrent otorrhoea
bull Disabling conductive hearing loss bull Bilateral ( gt30 - 40 dB)
bull Unilateral
bull To allow watersports
Wullstein Classification of Tympanoplasty (1956)
bull Type I ndash Myringoplasty = 3 ossicles present amp drum repair
bull Type II ndash Malleusincus eroded ndash reconstruction preserves middle ear depth
bull Type III ndash Lateral ossicles gone graft onto stapes superstructure columella effect shallow ME cleft
bull Type IV ndash No ossicles graft onto footplate
bull Type V ndash graft onto fixed footplate Va = fenestration of LSSC
Tympoanoplasty Type 1 in children ndash an evaluative study
bull Gautam Bir Sing et al Int J Ped Otorninolaryngol 200569 (8)1071-76
bull 80 graft success rate at 6 month
bull 61 significant improved hearing
Meta-analysis of Pediatric Tympanoplasty
bull Vrabec et al Arch Otolaryngol H amp Neck Surg 1999 125 (5) 530-34
bull Graft take rate 80 in perf less than half TM
69 if over half TM
bull Take rate with good vs poor ET function 87 cf 77
bull Adenoids ndash no difference
bull Normal contralat ear vs abnormal 80 cf 71
bull Wet ear ndash no difference
bull Increased success rate with increasing Age (p =0005)
What Age to perform myringoplasty
bull Success rate not influenced by age (eg House Ear Institute
Chandrasekhar et al Arch Oto HampN Surg 1995 121873-878 and Denoyelle Garabedien group Paris Laryngoscope)
bull Mean age of most paediatric published series = 10 ndash 11 years (range 4 ndash 17)
bull General Advice (GMorrison) ndash Other ear predicts outcome ndash 7 ndash 8 yrs or over if infections controllable and one good
hearing ear ndash As early as 3 ndash 4 if bilat Subtotal perfs with disabling
hearing loss amp infections
Myringoplasty ndash Personal Surgical tips
bull Consider periosteum graft
bull Dry graft thoroughly
bull Trim graft to exact size (little finger nail)
bull Underlay or reverse thru-lay technique
bull ldquoKerrrdquo ant wall pocket if no anterior lip
bull Subcuticular resorbable sutures
bull BIPP pack(s) except v young
EAM
ME
Anterior
Cartilage Tympanoplasty
bull Jansen 1958
bull Heerman 1962 ndash cartilage palisade
bull Techniques
ndash Island graft
ndash Palisades
ndash Butterfly inlay
ndash Cartilage Shield
Indications for Cartilage Tympanoplasty
bull Retraction pockets
bull Atelectasis
bull Poor ET Function
bull To prevent prosthesis extrusion
bull (Revision Surgery)
Reinforcement Tympanoplasty for retraction
Post Cartilage Tympanoplasty amp Incus transposition
Surgical Outcomes for Paediatric Myringoplasty
bull Fat plug Myringoplasty ndash 80 success bull Paper - steristrip myringoplasty ndash 65 bull Formal Myringoplasty - over 80 closure - 60 - 81 hearing
success bull Hearing gain - ABG to lt 10 dB to 23 lt20 dB in 883
Risk of OME after repair ndash 78 Long term graft breakdown ndash 65
Wet Ear Surgery
bull Moist ear ndash OK
bull Purulent Ear ndash Surgery Contraindicated
Conclusions
bull AOM and CSOM without cholesteatoma can lead to intracranial complications
bull Persistent perforations post grommets are seen in up to 46 patients
bull Operate when ET function improved
bull Cartilage Tympanoplasty has advantages in special cases
bull You can routinely repair ears at 8 years
bull Surgery best avoided in a purulent ear
Thank You
Stable vs Unstable
Stable = ldquoDryrdquo
bull Non-erosive non progressive
bull Not getting infections
bull No build up of keratin
CONSERVATIVE - IF GOOD HEARING
Unstable Attic Retraction
OPERATE
Pars Tensa Retractions
Pars Tensa Retractions
Dilemma
Early Surgery vs Late Surgery
Avoid ossicle erosion May get Hearing loss
Prevent Colesteatoma May get cholesteatoma
Can cause worse hearing
Management Options for Pars Tensa Retraction Pockets
bull Conservative ndash Observation amp serial audiometry +- CT
bull Surgical ndash Ventilation tube
ndash Excision of Pocket alone
ndash Excision of pocket with grafting
ndash Excision +- graft + Grommet
ndash Cartilage reinforcement tympanoplasty
Can the Literature give us the answers
helliphelliphelliphelliphelliphellip
Pars tensa Retractions in children by excision and ventilation tubes
bull Srinivasan V et al - Clin Otolaryngol Allied Sci 2000 25(4)253-6
bull 74 TM healing
bull 22 Re-retraction
Cochrane Review ndash Surgery for Tympanic Membrane Retraction Pockets
bull Nankivell PC and Pothier DD
bull 2010
bull 42 studies ndash 2 RCTs
bull Barbara 2008 (attic reconstruction) amp Elsheikh 2006 (pars tensa repair + - T tube)
bull ldquoNo statistical benefit of surgical interventionrdquo
bull ldquoThere is currently no good evidence for the role of any individual surgical intervention for the management of atelectasis of the tympanic membranerdquo
BUT
bull One Year Follow up only
bull No mention of attic retraction even though one paper only concerned this
Pars Tensa retractions - Natural History
bull TARGET trial ndash MISLEADING bull Retractions are spontaneously variable with time and may be reversible
bull Postero-superior retractions lead to 1o acquired
cholesteatomas (Sudhoff HolgerTos Mirko Pathogenesis of Attic Cholesteatoma Clinical
and Immunohistochemical Support for Combination of Retraction Theory and Proliferation Theory American Journal of Otology 2000 21(6)786-792)
Examples Pars Tensa retractions
Pars tensa retraction - What are you going to do
What are you going to do
How do you know if this retraction is going to progress
Grommets for Pars tensa retraction Pockets if under 10 and
bull Stage 1 and hearing loss from OME
bull Stage 2 and hearing loss or GENUINE erosion of LPI noted
bull Stage 3 with HL
bull Atelectasis Stage 4
Strategy for Pars Tensa Retractions
bull Use otoendoscope if limit not seen
bull Younger child ndash Repeated Ventilation tubes of hearing loss
bull Older child ndash consider excision amp grafting
bull Always montior the ME pressure -ve = delay surgery
bull Progressive or unstable poster-superior retraction - Operate
bull If hearing loss ndash offer surgery
bull Decision also depends on status of contralat ear age of patient amp historic
rate of progression
Reconstructive surgery for P tensa retraction if
bull Grade III retraction when adolescent
bull Retraction limits not seen in facial recess sinus tympani and unstable ndash periodic infections
bull Retraction into facial recess sinus tympani amp tympanogram improving
bull Grade IV retraction when adolescent
Mild retractionGood hearing
Pars tensa retraction pocket Atelectasiscollapse
Deep retractionEarly LPI erosion
Good or bad hearing
grommets
Glue earHearing loss
Trial grommets
Unstable retractionLimit of pocket out of view
Ossicular erosion
Reinforcement tympanoplasty+- ossiculoplasty
+- long term ventilation tube
Observation extrudes
Resolved discharge patient
lt10 years gt10 years
Failure
Summary
bull Classifications described
bull Vent Tubes correct Ptensa retractn while in situ
bull Postero-superior pockets can erode ossicles amp develop cholesteatoma
bull Surgery can be preventative or corrective
bull Operate if poor hearing or progression over time
bull Balance risks of surgery vs risks of non-intervention
bull Cartilage repair has gained popularity
Perforations
Safe vs Unsafe ears
bull Brain abscess
After cholesteatoma in 46
After mucosal disease in 38
After mod Rad mastoidectomy in 15
Browning GG The Unsafeness of safe ears JLO 1984a 9823-26
Aetiologies of TM Perforations
bull AOM perforation bull Otitis Externa ndash myringitis (fungal) bull CSOM bull Specific Chronic Suppurative Otitis Media TB Actinomyces Syphilis
bull Direct trauma to membrane bull Post ventilation tubes (275 ear 46 child 13 t-tubes)
bull Barotraumatic bull Blast Injury beware implantation
cholesteatoma
Size Matters
bull Conductive Hearing Loss variable 0 ndash 50 dB
bull Larger perforation = larger ABG
bull Low frequencies greatest affected
bull Post frac12 TM ndash transmits low frequency
bull Ant frac12 TM transmits high frequency
Management of TM perforations
bull Conservative ldquoA small perforation is good it acts as a natural ventilation
tuberdquo
Small hole no infections good hearing poor ETD = leave alone
bull Surgical ldquoThe perforation is bad it leads to recurrent ear infections
and restricts water sportsrdquo
Recurrent infections hearing loss other ear good = repair
Management of TM perforations
bull Conservative
bull Swabs + microsuction
bull Keep ear dry (earplugs for swimming)
bull Topical Agents - Ofloxacin or Ciprofloxacin drops + steroids
bull Systemic antibiotics
Management of TM perforations
bull Surgical
ndash Myringoplasty Tympanoplasty
ndash + - Adenoidectomy
Indications for repair of perforation
bull Any Ear with cholesteatoma
bull Not healed spontaneously after 6 months observation
andhellip
bull Recurrent otorrhoea
bull Disabling conductive hearing loss bull Bilateral ( gt30 - 40 dB)
bull Unilateral
bull To allow watersports
Wullstein Classification of Tympanoplasty (1956)
bull Type I ndash Myringoplasty = 3 ossicles present amp drum repair
bull Type II ndash Malleusincus eroded ndash reconstruction preserves middle ear depth
bull Type III ndash Lateral ossicles gone graft onto stapes superstructure columella effect shallow ME cleft
bull Type IV ndash No ossicles graft onto footplate
bull Type V ndash graft onto fixed footplate Va = fenestration of LSSC
Tympoanoplasty Type 1 in children ndash an evaluative study
bull Gautam Bir Sing et al Int J Ped Otorninolaryngol 200569 (8)1071-76
bull 80 graft success rate at 6 month
bull 61 significant improved hearing
Meta-analysis of Pediatric Tympanoplasty
bull Vrabec et al Arch Otolaryngol H amp Neck Surg 1999 125 (5) 530-34
bull Graft take rate 80 in perf less than half TM
69 if over half TM
bull Take rate with good vs poor ET function 87 cf 77
bull Adenoids ndash no difference
bull Normal contralat ear vs abnormal 80 cf 71
bull Wet ear ndash no difference
bull Increased success rate with increasing Age (p =0005)
What Age to perform myringoplasty
bull Success rate not influenced by age (eg House Ear Institute
Chandrasekhar et al Arch Oto HampN Surg 1995 121873-878 and Denoyelle Garabedien group Paris Laryngoscope)
bull Mean age of most paediatric published series = 10 ndash 11 years (range 4 ndash 17)
bull General Advice (GMorrison) ndash Other ear predicts outcome ndash 7 ndash 8 yrs or over if infections controllable and one good
hearing ear ndash As early as 3 ndash 4 if bilat Subtotal perfs with disabling
hearing loss amp infections
Myringoplasty ndash Personal Surgical tips
bull Consider periosteum graft
bull Dry graft thoroughly
bull Trim graft to exact size (little finger nail)
bull Underlay or reverse thru-lay technique
bull ldquoKerrrdquo ant wall pocket if no anterior lip
bull Subcuticular resorbable sutures
bull BIPP pack(s) except v young
EAM
ME
Anterior
Cartilage Tympanoplasty
bull Jansen 1958
bull Heerman 1962 ndash cartilage palisade
bull Techniques
ndash Island graft
ndash Palisades
ndash Butterfly inlay
ndash Cartilage Shield
Indications for Cartilage Tympanoplasty
bull Retraction pockets
bull Atelectasis
bull Poor ET Function
bull To prevent prosthesis extrusion
bull (Revision Surgery)
Reinforcement Tympanoplasty for retraction
Post Cartilage Tympanoplasty amp Incus transposition
Surgical Outcomes for Paediatric Myringoplasty
bull Fat plug Myringoplasty ndash 80 success bull Paper - steristrip myringoplasty ndash 65 bull Formal Myringoplasty - over 80 closure - 60 - 81 hearing
success bull Hearing gain - ABG to lt 10 dB to 23 lt20 dB in 883
Risk of OME after repair ndash 78 Long term graft breakdown ndash 65
Wet Ear Surgery
bull Moist ear ndash OK
bull Purulent Ear ndash Surgery Contraindicated
Conclusions
bull AOM and CSOM without cholesteatoma can lead to intracranial complications
bull Persistent perforations post grommets are seen in up to 46 patients
bull Operate when ET function improved
bull Cartilage Tympanoplasty has advantages in special cases
bull You can routinely repair ears at 8 years
bull Surgery best avoided in a purulent ear
Thank You
Unstable Attic Retraction
OPERATE
Pars Tensa Retractions
Pars Tensa Retractions
Dilemma
Early Surgery vs Late Surgery
Avoid ossicle erosion May get Hearing loss
Prevent Colesteatoma May get cholesteatoma
Can cause worse hearing
Management Options for Pars Tensa Retraction Pockets
bull Conservative ndash Observation amp serial audiometry +- CT
bull Surgical ndash Ventilation tube
ndash Excision of Pocket alone
ndash Excision of pocket with grafting
ndash Excision +- graft + Grommet
ndash Cartilage reinforcement tympanoplasty
Can the Literature give us the answers
helliphelliphelliphelliphelliphellip
Pars tensa Retractions in children by excision and ventilation tubes
bull Srinivasan V et al - Clin Otolaryngol Allied Sci 2000 25(4)253-6
bull 74 TM healing
bull 22 Re-retraction
Cochrane Review ndash Surgery for Tympanic Membrane Retraction Pockets
bull Nankivell PC and Pothier DD
bull 2010
bull 42 studies ndash 2 RCTs
bull Barbara 2008 (attic reconstruction) amp Elsheikh 2006 (pars tensa repair + - T tube)
bull ldquoNo statistical benefit of surgical interventionrdquo
bull ldquoThere is currently no good evidence for the role of any individual surgical intervention for the management of atelectasis of the tympanic membranerdquo
BUT
bull One Year Follow up only
bull No mention of attic retraction even though one paper only concerned this
Pars Tensa retractions - Natural History
bull TARGET trial ndash MISLEADING bull Retractions are spontaneously variable with time and may be reversible
bull Postero-superior retractions lead to 1o acquired
cholesteatomas (Sudhoff HolgerTos Mirko Pathogenesis of Attic Cholesteatoma Clinical
and Immunohistochemical Support for Combination of Retraction Theory and Proliferation Theory American Journal of Otology 2000 21(6)786-792)
Examples Pars Tensa retractions
Pars tensa retraction - What are you going to do
What are you going to do
How do you know if this retraction is going to progress
Grommets for Pars tensa retraction Pockets if under 10 and
bull Stage 1 and hearing loss from OME
bull Stage 2 and hearing loss or GENUINE erosion of LPI noted
bull Stage 3 with HL
bull Atelectasis Stage 4
Strategy for Pars Tensa Retractions
bull Use otoendoscope if limit not seen
bull Younger child ndash Repeated Ventilation tubes of hearing loss
bull Older child ndash consider excision amp grafting
bull Always montior the ME pressure -ve = delay surgery
bull Progressive or unstable poster-superior retraction - Operate
bull If hearing loss ndash offer surgery
bull Decision also depends on status of contralat ear age of patient amp historic
rate of progression
Reconstructive surgery for P tensa retraction if
bull Grade III retraction when adolescent
bull Retraction limits not seen in facial recess sinus tympani and unstable ndash periodic infections
bull Retraction into facial recess sinus tympani amp tympanogram improving
bull Grade IV retraction when adolescent
Mild retractionGood hearing
Pars tensa retraction pocket Atelectasiscollapse
Deep retractionEarly LPI erosion
Good or bad hearing
grommets
Glue earHearing loss
Trial grommets
Unstable retractionLimit of pocket out of view
Ossicular erosion
Reinforcement tympanoplasty+- ossiculoplasty
+- long term ventilation tube
Observation extrudes
Resolved discharge patient
lt10 years gt10 years
Failure
Summary
bull Classifications described
bull Vent Tubes correct Ptensa retractn while in situ
bull Postero-superior pockets can erode ossicles amp develop cholesteatoma
bull Surgery can be preventative or corrective
bull Operate if poor hearing or progression over time
bull Balance risks of surgery vs risks of non-intervention
bull Cartilage repair has gained popularity
Perforations
Safe vs Unsafe ears
bull Brain abscess
After cholesteatoma in 46
After mucosal disease in 38
After mod Rad mastoidectomy in 15
Browning GG The Unsafeness of safe ears JLO 1984a 9823-26
Aetiologies of TM Perforations
bull AOM perforation bull Otitis Externa ndash myringitis (fungal) bull CSOM bull Specific Chronic Suppurative Otitis Media TB Actinomyces Syphilis
bull Direct trauma to membrane bull Post ventilation tubes (275 ear 46 child 13 t-tubes)
bull Barotraumatic bull Blast Injury beware implantation
cholesteatoma
Size Matters
bull Conductive Hearing Loss variable 0 ndash 50 dB
bull Larger perforation = larger ABG
bull Low frequencies greatest affected
bull Post frac12 TM ndash transmits low frequency
bull Ant frac12 TM transmits high frequency
Management of TM perforations
bull Conservative ldquoA small perforation is good it acts as a natural ventilation
tuberdquo
Small hole no infections good hearing poor ETD = leave alone
bull Surgical ldquoThe perforation is bad it leads to recurrent ear infections
and restricts water sportsrdquo
Recurrent infections hearing loss other ear good = repair
Management of TM perforations
bull Conservative
bull Swabs + microsuction
bull Keep ear dry (earplugs for swimming)
bull Topical Agents - Ofloxacin or Ciprofloxacin drops + steroids
bull Systemic antibiotics
Management of TM perforations
bull Surgical
ndash Myringoplasty Tympanoplasty
ndash + - Adenoidectomy
Indications for repair of perforation
bull Any Ear with cholesteatoma
bull Not healed spontaneously after 6 months observation
andhellip
bull Recurrent otorrhoea
bull Disabling conductive hearing loss bull Bilateral ( gt30 - 40 dB)
bull Unilateral
bull To allow watersports
Wullstein Classification of Tympanoplasty (1956)
bull Type I ndash Myringoplasty = 3 ossicles present amp drum repair
bull Type II ndash Malleusincus eroded ndash reconstruction preserves middle ear depth
bull Type III ndash Lateral ossicles gone graft onto stapes superstructure columella effect shallow ME cleft
bull Type IV ndash No ossicles graft onto footplate
bull Type V ndash graft onto fixed footplate Va = fenestration of LSSC
Tympoanoplasty Type 1 in children ndash an evaluative study
bull Gautam Bir Sing et al Int J Ped Otorninolaryngol 200569 (8)1071-76
bull 80 graft success rate at 6 month
bull 61 significant improved hearing
Meta-analysis of Pediatric Tympanoplasty
bull Vrabec et al Arch Otolaryngol H amp Neck Surg 1999 125 (5) 530-34
bull Graft take rate 80 in perf less than half TM
69 if over half TM
bull Take rate with good vs poor ET function 87 cf 77
bull Adenoids ndash no difference
bull Normal contralat ear vs abnormal 80 cf 71
bull Wet ear ndash no difference
bull Increased success rate with increasing Age (p =0005)
What Age to perform myringoplasty
bull Success rate not influenced by age (eg House Ear Institute
Chandrasekhar et al Arch Oto HampN Surg 1995 121873-878 and Denoyelle Garabedien group Paris Laryngoscope)
bull Mean age of most paediatric published series = 10 ndash 11 years (range 4 ndash 17)
bull General Advice (GMorrison) ndash Other ear predicts outcome ndash 7 ndash 8 yrs or over if infections controllable and one good
hearing ear ndash As early as 3 ndash 4 if bilat Subtotal perfs with disabling
hearing loss amp infections
Myringoplasty ndash Personal Surgical tips
bull Consider periosteum graft
bull Dry graft thoroughly
bull Trim graft to exact size (little finger nail)
bull Underlay or reverse thru-lay technique
bull ldquoKerrrdquo ant wall pocket if no anterior lip
bull Subcuticular resorbable sutures
bull BIPP pack(s) except v young
EAM
ME
Anterior
Cartilage Tympanoplasty
bull Jansen 1958
bull Heerman 1962 ndash cartilage palisade
bull Techniques
ndash Island graft
ndash Palisades
ndash Butterfly inlay
ndash Cartilage Shield
Indications for Cartilage Tympanoplasty
bull Retraction pockets
bull Atelectasis
bull Poor ET Function
bull To prevent prosthesis extrusion
bull (Revision Surgery)
Reinforcement Tympanoplasty for retraction
Post Cartilage Tympanoplasty amp Incus transposition
Surgical Outcomes for Paediatric Myringoplasty
bull Fat plug Myringoplasty ndash 80 success bull Paper - steristrip myringoplasty ndash 65 bull Formal Myringoplasty - over 80 closure - 60 - 81 hearing
success bull Hearing gain - ABG to lt 10 dB to 23 lt20 dB in 883
Risk of OME after repair ndash 78 Long term graft breakdown ndash 65
Wet Ear Surgery
bull Moist ear ndash OK
bull Purulent Ear ndash Surgery Contraindicated
Conclusions
bull AOM and CSOM without cholesteatoma can lead to intracranial complications
bull Persistent perforations post grommets are seen in up to 46 patients
bull Operate when ET function improved
bull Cartilage Tympanoplasty has advantages in special cases
bull You can routinely repair ears at 8 years
bull Surgery best avoided in a purulent ear
Thank You
Pars Tensa Retractions
Pars Tensa Retractions
Dilemma
Early Surgery vs Late Surgery
Avoid ossicle erosion May get Hearing loss
Prevent Colesteatoma May get cholesteatoma
Can cause worse hearing
Management Options for Pars Tensa Retraction Pockets
bull Conservative ndash Observation amp serial audiometry +- CT
bull Surgical ndash Ventilation tube
ndash Excision of Pocket alone
ndash Excision of pocket with grafting
ndash Excision +- graft + Grommet
ndash Cartilage reinforcement tympanoplasty
Can the Literature give us the answers
helliphelliphelliphelliphelliphellip
Pars tensa Retractions in children by excision and ventilation tubes
bull Srinivasan V et al - Clin Otolaryngol Allied Sci 2000 25(4)253-6
bull 74 TM healing
bull 22 Re-retraction
Cochrane Review ndash Surgery for Tympanic Membrane Retraction Pockets
bull Nankivell PC and Pothier DD
bull 2010
bull 42 studies ndash 2 RCTs
bull Barbara 2008 (attic reconstruction) amp Elsheikh 2006 (pars tensa repair + - T tube)
bull ldquoNo statistical benefit of surgical interventionrdquo
bull ldquoThere is currently no good evidence for the role of any individual surgical intervention for the management of atelectasis of the tympanic membranerdquo
BUT
bull One Year Follow up only
bull No mention of attic retraction even though one paper only concerned this
Pars Tensa retractions - Natural History
bull TARGET trial ndash MISLEADING bull Retractions are spontaneously variable with time and may be reversible
bull Postero-superior retractions lead to 1o acquired
cholesteatomas (Sudhoff HolgerTos Mirko Pathogenesis of Attic Cholesteatoma Clinical
and Immunohistochemical Support for Combination of Retraction Theory and Proliferation Theory American Journal of Otology 2000 21(6)786-792)
Examples Pars Tensa retractions
Pars tensa retraction - What are you going to do
What are you going to do
How do you know if this retraction is going to progress
Grommets for Pars tensa retraction Pockets if under 10 and
bull Stage 1 and hearing loss from OME
bull Stage 2 and hearing loss or GENUINE erosion of LPI noted
bull Stage 3 with HL
bull Atelectasis Stage 4
Strategy for Pars Tensa Retractions
bull Use otoendoscope if limit not seen
bull Younger child ndash Repeated Ventilation tubes of hearing loss
bull Older child ndash consider excision amp grafting
bull Always montior the ME pressure -ve = delay surgery
bull Progressive or unstable poster-superior retraction - Operate
bull If hearing loss ndash offer surgery
bull Decision also depends on status of contralat ear age of patient amp historic
rate of progression
Reconstructive surgery for P tensa retraction if
bull Grade III retraction when adolescent
bull Retraction limits not seen in facial recess sinus tympani and unstable ndash periodic infections
bull Retraction into facial recess sinus tympani amp tympanogram improving
bull Grade IV retraction when adolescent
Mild retractionGood hearing
Pars tensa retraction pocket Atelectasiscollapse
Deep retractionEarly LPI erosion
Good or bad hearing
grommets
Glue earHearing loss
Trial grommets
Unstable retractionLimit of pocket out of view
Ossicular erosion
Reinforcement tympanoplasty+- ossiculoplasty
+- long term ventilation tube
Observation extrudes
Resolved discharge patient
lt10 years gt10 years
Failure
Summary
bull Classifications described
bull Vent Tubes correct Ptensa retractn while in situ
bull Postero-superior pockets can erode ossicles amp develop cholesteatoma
bull Surgery can be preventative or corrective
bull Operate if poor hearing or progression over time
bull Balance risks of surgery vs risks of non-intervention
bull Cartilage repair has gained popularity
Perforations
Safe vs Unsafe ears
bull Brain abscess
After cholesteatoma in 46
After mucosal disease in 38
After mod Rad mastoidectomy in 15
Browning GG The Unsafeness of safe ears JLO 1984a 9823-26
Aetiologies of TM Perforations
bull AOM perforation bull Otitis Externa ndash myringitis (fungal) bull CSOM bull Specific Chronic Suppurative Otitis Media TB Actinomyces Syphilis
bull Direct trauma to membrane bull Post ventilation tubes (275 ear 46 child 13 t-tubes)
bull Barotraumatic bull Blast Injury beware implantation
cholesteatoma
Size Matters
bull Conductive Hearing Loss variable 0 ndash 50 dB
bull Larger perforation = larger ABG
bull Low frequencies greatest affected
bull Post frac12 TM ndash transmits low frequency
bull Ant frac12 TM transmits high frequency
Management of TM perforations
bull Conservative ldquoA small perforation is good it acts as a natural ventilation
tuberdquo
Small hole no infections good hearing poor ETD = leave alone
bull Surgical ldquoThe perforation is bad it leads to recurrent ear infections
and restricts water sportsrdquo
Recurrent infections hearing loss other ear good = repair
Management of TM perforations
bull Conservative
bull Swabs + microsuction
bull Keep ear dry (earplugs for swimming)
bull Topical Agents - Ofloxacin or Ciprofloxacin drops + steroids
bull Systemic antibiotics
Management of TM perforations
bull Surgical
ndash Myringoplasty Tympanoplasty
ndash + - Adenoidectomy
Indications for repair of perforation
bull Any Ear with cholesteatoma
bull Not healed spontaneously after 6 months observation
andhellip
bull Recurrent otorrhoea
bull Disabling conductive hearing loss bull Bilateral ( gt30 - 40 dB)
bull Unilateral
bull To allow watersports
Wullstein Classification of Tympanoplasty (1956)
bull Type I ndash Myringoplasty = 3 ossicles present amp drum repair
bull Type II ndash Malleusincus eroded ndash reconstruction preserves middle ear depth
bull Type III ndash Lateral ossicles gone graft onto stapes superstructure columella effect shallow ME cleft
bull Type IV ndash No ossicles graft onto footplate
bull Type V ndash graft onto fixed footplate Va = fenestration of LSSC
Tympoanoplasty Type 1 in children ndash an evaluative study
bull Gautam Bir Sing et al Int J Ped Otorninolaryngol 200569 (8)1071-76
bull 80 graft success rate at 6 month
bull 61 significant improved hearing
Meta-analysis of Pediatric Tympanoplasty
bull Vrabec et al Arch Otolaryngol H amp Neck Surg 1999 125 (5) 530-34
bull Graft take rate 80 in perf less than half TM
69 if over half TM
bull Take rate with good vs poor ET function 87 cf 77
bull Adenoids ndash no difference
bull Normal contralat ear vs abnormal 80 cf 71
bull Wet ear ndash no difference
bull Increased success rate with increasing Age (p =0005)
What Age to perform myringoplasty
bull Success rate not influenced by age (eg House Ear Institute
Chandrasekhar et al Arch Oto HampN Surg 1995 121873-878 and Denoyelle Garabedien group Paris Laryngoscope)
bull Mean age of most paediatric published series = 10 ndash 11 years (range 4 ndash 17)
bull General Advice (GMorrison) ndash Other ear predicts outcome ndash 7 ndash 8 yrs or over if infections controllable and one good
hearing ear ndash As early as 3 ndash 4 if bilat Subtotal perfs with disabling
hearing loss amp infections
Myringoplasty ndash Personal Surgical tips
bull Consider periosteum graft
bull Dry graft thoroughly
bull Trim graft to exact size (little finger nail)
bull Underlay or reverse thru-lay technique
bull ldquoKerrrdquo ant wall pocket if no anterior lip
bull Subcuticular resorbable sutures
bull BIPP pack(s) except v young
EAM
ME
Anterior
Cartilage Tympanoplasty
bull Jansen 1958
bull Heerman 1962 ndash cartilage palisade
bull Techniques
ndash Island graft
ndash Palisades
ndash Butterfly inlay
ndash Cartilage Shield
Indications for Cartilage Tympanoplasty
bull Retraction pockets
bull Atelectasis
bull Poor ET Function
bull To prevent prosthesis extrusion
bull (Revision Surgery)
Reinforcement Tympanoplasty for retraction
Post Cartilage Tympanoplasty amp Incus transposition
Surgical Outcomes for Paediatric Myringoplasty
bull Fat plug Myringoplasty ndash 80 success bull Paper - steristrip myringoplasty ndash 65 bull Formal Myringoplasty - over 80 closure - 60 - 81 hearing
success bull Hearing gain - ABG to lt 10 dB to 23 lt20 dB in 883
Risk of OME after repair ndash 78 Long term graft breakdown ndash 65
Wet Ear Surgery
bull Moist ear ndash OK
bull Purulent Ear ndash Surgery Contraindicated
Conclusions
bull AOM and CSOM without cholesteatoma can lead to intracranial complications
bull Persistent perforations post grommets are seen in up to 46 patients
bull Operate when ET function improved
bull Cartilage Tympanoplasty has advantages in special cases
bull You can routinely repair ears at 8 years
bull Surgery best avoided in a purulent ear
Thank You
Pars Tensa Retractions
Dilemma
Early Surgery vs Late Surgery
Avoid ossicle erosion May get Hearing loss
Prevent Colesteatoma May get cholesteatoma
Can cause worse hearing
Management Options for Pars Tensa Retraction Pockets
bull Conservative ndash Observation amp serial audiometry +- CT
bull Surgical ndash Ventilation tube
ndash Excision of Pocket alone
ndash Excision of pocket with grafting
ndash Excision +- graft + Grommet
ndash Cartilage reinforcement tympanoplasty
Can the Literature give us the answers
helliphelliphelliphelliphelliphellip
Pars tensa Retractions in children by excision and ventilation tubes
bull Srinivasan V et al - Clin Otolaryngol Allied Sci 2000 25(4)253-6
bull 74 TM healing
bull 22 Re-retraction
Cochrane Review ndash Surgery for Tympanic Membrane Retraction Pockets
bull Nankivell PC and Pothier DD
bull 2010
bull 42 studies ndash 2 RCTs
bull Barbara 2008 (attic reconstruction) amp Elsheikh 2006 (pars tensa repair + - T tube)
bull ldquoNo statistical benefit of surgical interventionrdquo
bull ldquoThere is currently no good evidence for the role of any individual surgical intervention for the management of atelectasis of the tympanic membranerdquo
BUT
bull One Year Follow up only
bull No mention of attic retraction even though one paper only concerned this
Pars Tensa retractions - Natural History
bull TARGET trial ndash MISLEADING bull Retractions are spontaneously variable with time and may be reversible
bull Postero-superior retractions lead to 1o acquired
cholesteatomas (Sudhoff HolgerTos Mirko Pathogenesis of Attic Cholesteatoma Clinical
and Immunohistochemical Support for Combination of Retraction Theory and Proliferation Theory American Journal of Otology 2000 21(6)786-792)
Examples Pars Tensa retractions
Pars tensa retraction - What are you going to do
What are you going to do
How do you know if this retraction is going to progress
Grommets for Pars tensa retraction Pockets if under 10 and
bull Stage 1 and hearing loss from OME
bull Stage 2 and hearing loss or GENUINE erosion of LPI noted
bull Stage 3 with HL
bull Atelectasis Stage 4
Strategy for Pars Tensa Retractions
bull Use otoendoscope if limit not seen
bull Younger child ndash Repeated Ventilation tubes of hearing loss
bull Older child ndash consider excision amp grafting
bull Always montior the ME pressure -ve = delay surgery
bull Progressive or unstable poster-superior retraction - Operate
bull If hearing loss ndash offer surgery
bull Decision also depends on status of contralat ear age of patient amp historic
rate of progression
Reconstructive surgery for P tensa retraction if
bull Grade III retraction when adolescent
bull Retraction limits not seen in facial recess sinus tympani and unstable ndash periodic infections
bull Retraction into facial recess sinus tympani amp tympanogram improving
bull Grade IV retraction when adolescent
Mild retractionGood hearing
Pars tensa retraction pocket Atelectasiscollapse
Deep retractionEarly LPI erosion
Good or bad hearing
grommets
Glue earHearing loss
Trial grommets
Unstable retractionLimit of pocket out of view
Ossicular erosion
Reinforcement tympanoplasty+- ossiculoplasty
+- long term ventilation tube
Observation extrudes
Resolved discharge patient
lt10 years gt10 years
Failure
Summary
bull Classifications described
bull Vent Tubes correct Ptensa retractn while in situ
bull Postero-superior pockets can erode ossicles amp develop cholesteatoma
bull Surgery can be preventative or corrective
bull Operate if poor hearing or progression over time
bull Balance risks of surgery vs risks of non-intervention
bull Cartilage repair has gained popularity
Perforations
Safe vs Unsafe ears
bull Brain abscess
After cholesteatoma in 46
After mucosal disease in 38
After mod Rad mastoidectomy in 15
Browning GG The Unsafeness of safe ears JLO 1984a 9823-26
Aetiologies of TM Perforations
bull AOM perforation bull Otitis Externa ndash myringitis (fungal) bull CSOM bull Specific Chronic Suppurative Otitis Media TB Actinomyces Syphilis
bull Direct trauma to membrane bull Post ventilation tubes (275 ear 46 child 13 t-tubes)
bull Barotraumatic bull Blast Injury beware implantation
cholesteatoma
Size Matters
bull Conductive Hearing Loss variable 0 ndash 50 dB
bull Larger perforation = larger ABG
bull Low frequencies greatest affected
bull Post frac12 TM ndash transmits low frequency
bull Ant frac12 TM transmits high frequency
Management of TM perforations
bull Conservative ldquoA small perforation is good it acts as a natural ventilation
tuberdquo
Small hole no infections good hearing poor ETD = leave alone
bull Surgical ldquoThe perforation is bad it leads to recurrent ear infections
and restricts water sportsrdquo
Recurrent infections hearing loss other ear good = repair
Management of TM perforations
bull Conservative
bull Swabs + microsuction
bull Keep ear dry (earplugs for swimming)
bull Topical Agents - Ofloxacin or Ciprofloxacin drops + steroids
bull Systemic antibiotics
Management of TM perforations
bull Surgical
ndash Myringoplasty Tympanoplasty
ndash + - Adenoidectomy
Indications for repair of perforation
bull Any Ear with cholesteatoma
bull Not healed spontaneously after 6 months observation
andhellip
bull Recurrent otorrhoea
bull Disabling conductive hearing loss bull Bilateral ( gt30 - 40 dB)
bull Unilateral
bull To allow watersports
Wullstein Classification of Tympanoplasty (1956)
bull Type I ndash Myringoplasty = 3 ossicles present amp drum repair
bull Type II ndash Malleusincus eroded ndash reconstruction preserves middle ear depth
bull Type III ndash Lateral ossicles gone graft onto stapes superstructure columella effect shallow ME cleft
bull Type IV ndash No ossicles graft onto footplate
bull Type V ndash graft onto fixed footplate Va = fenestration of LSSC
Tympoanoplasty Type 1 in children ndash an evaluative study
bull Gautam Bir Sing et al Int J Ped Otorninolaryngol 200569 (8)1071-76
bull 80 graft success rate at 6 month
bull 61 significant improved hearing
Meta-analysis of Pediatric Tympanoplasty
bull Vrabec et al Arch Otolaryngol H amp Neck Surg 1999 125 (5) 530-34
bull Graft take rate 80 in perf less than half TM
69 if over half TM
bull Take rate with good vs poor ET function 87 cf 77
bull Adenoids ndash no difference
bull Normal contralat ear vs abnormal 80 cf 71
bull Wet ear ndash no difference
bull Increased success rate with increasing Age (p =0005)
What Age to perform myringoplasty
bull Success rate not influenced by age (eg House Ear Institute
Chandrasekhar et al Arch Oto HampN Surg 1995 121873-878 and Denoyelle Garabedien group Paris Laryngoscope)
bull Mean age of most paediatric published series = 10 ndash 11 years (range 4 ndash 17)
bull General Advice (GMorrison) ndash Other ear predicts outcome ndash 7 ndash 8 yrs or over if infections controllable and one good
hearing ear ndash As early as 3 ndash 4 if bilat Subtotal perfs with disabling
hearing loss amp infections
Myringoplasty ndash Personal Surgical tips
bull Consider periosteum graft
bull Dry graft thoroughly
bull Trim graft to exact size (little finger nail)
bull Underlay or reverse thru-lay technique
bull ldquoKerrrdquo ant wall pocket if no anterior lip
bull Subcuticular resorbable sutures
bull BIPP pack(s) except v young
EAM
ME
Anterior
Cartilage Tympanoplasty
bull Jansen 1958
bull Heerman 1962 ndash cartilage palisade
bull Techniques
ndash Island graft
ndash Palisades
ndash Butterfly inlay
ndash Cartilage Shield
Indications for Cartilage Tympanoplasty
bull Retraction pockets
bull Atelectasis
bull Poor ET Function
bull To prevent prosthesis extrusion
bull (Revision Surgery)
Reinforcement Tympanoplasty for retraction
Post Cartilage Tympanoplasty amp Incus transposition
Surgical Outcomes for Paediatric Myringoplasty
bull Fat plug Myringoplasty ndash 80 success bull Paper - steristrip myringoplasty ndash 65 bull Formal Myringoplasty - over 80 closure - 60 - 81 hearing
success bull Hearing gain - ABG to lt 10 dB to 23 lt20 dB in 883
Risk of OME after repair ndash 78 Long term graft breakdown ndash 65
Wet Ear Surgery
bull Moist ear ndash OK
bull Purulent Ear ndash Surgery Contraindicated
Conclusions
bull AOM and CSOM without cholesteatoma can lead to intracranial complications
bull Persistent perforations post grommets are seen in up to 46 patients
bull Operate when ET function improved
bull Cartilage Tympanoplasty has advantages in special cases
bull You can routinely repair ears at 8 years
bull Surgery best avoided in a purulent ear
Thank You
Management Options for Pars Tensa Retraction Pockets
bull Conservative ndash Observation amp serial audiometry +- CT
bull Surgical ndash Ventilation tube
ndash Excision of Pocket alone
ndash Excision of pocket with grafting
ndash Excision +- graft + Grommet
ndash Cartilage reinforcement tympanoplasty
Can the Literature give us the answers
helliphelliphelliphelliphelliphellip
Pars tensa Retractions in children by excision and ventilation tubes
bull Srinivasan V et al - Clin Otolaryngol Allied Sci 2000 25(4)253-6
bull 74 TM healing
bull 22 Re-retraction
Cochrane Review ndash Surgery for Tympanic Membrane Retraction Pockets
bull Nankivell PC and Pothier DD
bull 2010
bull 42 studies ndash 2 RCTs
bull Barbara 2008 (attic reconstruction) amp Elsheikh 2006 (pars tensa repair + - T tube)
bull ldquoNo statistical benefit of surgical interventionrdquo
bull ldquoThere is currently no good evidence for the role of any individual surgical intervention for the management of atelectasis of the tympanic membranerdquo
BUT
bull One Year Follow up only
bull No mention of attic retraction even though one paper only concerned this
Pars Tensa retractions - Natural History
bull TARGET trial ndash MISLEADING bull Retractions are spontaneously variable with time and may be reversible
bull Postero-superior retractions lead to 1o acquired
cholesteatomas (Sudhoff HolgerTos Mirko Pathogenesis of Attic Cholesteatoma Clinical
and Immunohistochemical Support for Combination of Retraction Theory and Proliferation Theory American Journal of Otology 2000 21(6)786-792)
Examples Pars Tensa retractions
Pars tensa retraction - What are you going to do
What are you going to do
How do you know if this retraction is going to progress
Grommets for Pars tensa retraction Pockets if under 10 and
bull Stage 1 and hearing loss from OME
bull Stage 2 and hearing loss or GENUINE erosion of LPI noted
bull Stage 3 with HL
bull Atelectasis Stage 4
Strategy for Pars Tensa Retractions
bull Use otoendoscope if limit not seen
bull Younger child ndash Repeated Ventilation tubes of hearing loss
bull Older child ndash consider excision amp grafting
bull Always montior the ME pressure -ve = delay surgery
bull Progressive or unstable poster-superior retraction - Operate
bull If hearing loss ndash offer surgery
bull Decision also depends on status of contralat ear age of patient amp historic
rate of progression
Reconstructive surgery for P tensa retraction if
bull Grade III retraction when adolescent
bull Retraction limits not seen in facial recess sinus tympani and unstable ndash periodic infections
bull Retraction into facial recess sinus tympani amp tympanogram improving
bull Grade IV retraction when adolescent
Mild retractionGood hearing
Pars tensa retraction pocket Atelectasiscollapse
Deep retractionEarly LPI erosion
Good or bad hearing
grommets
Glue earHearing loss
Trial grommets
Unstable retractionLimit of pocket out of view
Ossicular erosion
Reinforcement tympanoplasty+- ossiculoplasty
+- long term ventilation tube
Observation extrudes
Resolved discharge patient
lt10 years gt10 years
Failure
Summary
bull Classifications described
bull Vent Tubes correct Ptensa retractn while in situ
bull Postero-superior pockets can erode ossicles amp develop cholesteatoma
bull Surgery can be preventative or corrective
bull Operate if poor hearing or progression over time
bull Balance risks of surgery vs risks of non-intervention
bull Cartilage repair has gained popularity
Perforations
Safe vs Unsafe ears
bull Brain abscess
After cholesteatoma in 46
After mucosal disease in 38
After mod Rad mastoidectomy in 15
Browning GG The Unsafeness of safe ears JLO 1984a 9823-26
Aetiologies of TM Perforations
bull AOM perforation bull Otitis Externa ndash myringitis (fungal) bull CSOM bull Specific Chronic Suppurative Otitis Media TB Actinomyces Syphilis
bull Direct trauma to membrane bull Post ventilation tubes (275 ear 46 child 13 t-tubes)
bull Barotraumatic bull Blast Injury beware implantation
cholesteatoma
Size Matters
bull Conductive Hearing Loss variable 0 ndash 50 dB
bull Larger perforation = larger ABG
bull Low frequencies greatest affected
bull Post frac12 TM ndash transmits low frequency
bull Ant frac12 TM transmits high frequency
Management of TM perforations
bull Conservative ldquoA small perforation is good it acts as a natural ventilation
tuberdquo
Small hole no infections good hearing poor ETD = leave alone
bull Surgical ldquoThe perforation is bad it leads to recurrent ear infections
and restricts water sportsrdquo
Recurrent infections hearing loss other ear good = repair
Management of TM perforations
bull Conservative
bull Swabs + microsuction
bull Keep ear dry (earplugs for swimming)
bull Topical Agents - Ofloxacin or Ciprofloxacin drops + steroids
bull Systemic antibiotics
Management of TM perforations
bull Surgical
ndash Myringoplasty Tympanoplasty
ndash + - Adenoidectomy
Indications for repair of perforation
bull Any Ear with cholesteatoma
bull Not healed spontaneously after 6 months observation
andhellip
bull Recurrent otorrhoea
bull Disabling conductive hearing loss bull Bilateral ( gt30 - 40 dB)
bull Unilateral
bull To allow watersports
Wullstein Classification of Tympanoplasty (1956)
bull Type I ndash Myringoplasty = 3 ossicles present amp drum repair
bull Type II ndash Malleusincus eroded ndash reconstruction preserves middle ear depth
bull Type III ndash Lateral ossicles gone graft onto stapes superstructure columella effect shallow ME cleft
bull Type IV ndash No ossicles graft onto footplate
bull Type V ndash graft onto fixed footplate Va = fenestration of LSSC
Tympoanoplasty Type 1 in children ndash an evaluative study
bull Gautam Bir Sing et al Int J Ped Otorninolaryngol 200569 (8)1071-76
bull 80 graft success rate at 6 month
bull 61 significant improved hearing
Meta-analysis of Pediatric Tympanoplasty
bull Vrabec et al Arch Otolaryngol H amp Neck Surg 1999 125 (5) 530-34
bull Graft take rate 80 in perf less than half TM
69 if over half TM
bull Take rate with good vs poor ET function 87 cf 77
bull Adenoids ndash no difference
bull Normal contralat ear vs abnormal 80 cf 71
bull Wet ear ndash no difference
bull Increased success rate with increasing Age (p =0005)
What Age to perform myringoplasty
bull Success rate not influenced by age (eg House Ear Institute
Chandrasekhar et al Arch Oto HampN Surg 1995 121873-878 and Denoyelle Garabedien group Paris Laryngoscope)
bull Mean age of most paediatric published series = 10 ndash 11 years (range 4 ndash 17)
bull General Advice (GMorrison) ndash Other ear predicts outcome ndash 7 ndash 8 yrs or over if infections controllable and one good
hearing ear ndash As early as 3 ndash 4 if bilat Subtotal perfs with disabling
hearing loss amp infections
Myringoplasty ndash Personal Surgical tips
bull Consider periosteum graft
bull Dry graft thoroughly
bull Trim graft to exact size (little finger nail)
bull Underlay or reverse thru-lay technique
bull ldquoKerrrdquo ant wall pocket if no anterior lip
bull Subcuticular resorbable sutures
bull BIPP pack(s) except v young
EAM
ME
Anterior
Cartilage Tympanoplasty
bull Jansen 1958
bull Heerman 1962 ndash cartilage palisade
bull Techniques
ndash Island graft
ndash Palisades
ndash Butterfly inlay
ndash Cartilage Shield
Indications for Cartilage Tympanoplasty
bull Retraction pockets
bull Atelectasis
bull Poor ET Function
bull To prevent prosthesis extrusion
bull (Revision Surgery)
Reinforcement Tympanoplasty for retraction
Post Cartilage Tympanoplasty amp Incus transposition
Surgical Outcomes for Paediatric Myringoplasty
bull Fat plug Myringoplasty ndash 80 success bull Paper - steristrip myringoplasty ndash 65 bull Formal Myringoplasty - over 80 closure - 60 - 81 hearing
success bull Hearing gain - ABG to lt 10 dB to 23 lt20 dB in 883
Risk of OME after repair ndash 78 Long term graft breakdown ndash 65
Wet Ear Surgery
bull Moist ear ndash OK
bull Purulent Ear ndash Surgery Contraindicated
Conclusions
bull AOM and CSOM without cholesteatoma can lead to intracranial complications
bull Persistent perforations post grommets are seen in up to 46 patients
bull Operate when ET function improved
bull Cartilage Tympanoplasty has advantages in special cases
bull You can routinely repair ears at 8 years
bull Surgery best avoided in a purulent ear
Thank You
Can the Literature give us the answers
helliphelliphelliphelliphelliphellip
Pars tensa Retractions in children by excision and ventilation tubes
bull Srinivasan V et al - Clin Otolaryngol Allied Sci 2000 25(4)253-6
bull 74 TM healing
bull 22 Re-retraction
Cochrane Review ndash Surgery for Tympanic Membrane Retraction Pockets
bull Nankivell PC and Pothier DD
bull 2010
bull 42 studies ndash 2 RCTs
bull Barbara 2008 (attic reconstruction) amp Elsheikh 2006 (pars tensa repair + - T tube)
bull ldquoNo statistical benefit of surgical interventionrdquo
bull ldquoThere is currently no good evidence for the role of any individual surgical intervention for the management of atelectasis of the tympanic membranerdquo
BUT
bull One Year Follow up only
bull No mention of attic retraction even though one paper only concerned this
Pars Tensa retractions - Natural History
bull TARGET trial ndash MISLEADING bull Retractions are spontaneously variable with time and may be reversible
bull Postero-superior retractions lead to 1o acquired
cholesteatomas (Sudhoff HolgerTos Mirko Pathogenesis of Attic Cholesteatoma Clinical
and Immunohistochemical Support for Combination of Retraction Theory and Proliferation Theory American Journal of Otology 2000 21(6)786-792)
Examples Pars Tensa retractions
Pars tensa retraction - What are you going to do
What are you going to do
How do you know if this retraction is going to progress
Grommets for Pars tensa retraction Pockets if under 10 and
bull Stage 1 and hearing loss from OME
bull Stage 2 and hearing loss or GENUINE erosion of LPI noted
bull Stage 3 with HL
bull Atelectasis Stage 4
Strategy for Pars Tensa Retractions
bull Use otoendoscope if limit not seen
bull Younger child ndash Repeated Ventilation tubes of hearing loss
bull Older child ndash consider excision amp grafting
bull Always montior the ME pressure -ve = delay surgery
bull Progressive or unstable poster-superior retraction - Operate
bull If hearing loss ndash offer surgery
bull Decision also depends on status of contralat ear age of patient amp historic
rate of progression
Reconstructive surgery for P tensa retraction if
bull Grade III retraction when adolescent
bull Retraction limits not seen in facial recess sinus tympani and unstable ndash periodic infections
bull Retraction into facial recess sinus tympani amp tympanogram improving
bull Grade IV retraction when adolescent
Mild retractionGood hearing
Pars tensa retraction pocket Atelectasiscollapse
Deep retractionEarly LPI erosion
Good or bad hearing
grommets
Glue earHearing loss
Trial grommets
Unstable retractionLimit of pocket out of view
Ossicular erosion
Reinforcement tympanoplasty+- ossiculoplasty
+- long term ventilation tube
Observation extrudes
Resolved discharge patient
lt10 years gt10 years
Failure
Summary
bull Classifications described
bull Vent Tubes correct Ptensa retractn while in situ
bull Postero-superior pockets can erode ossicles amp develop cholesteatoma
bull Surgery can be preventative or corrective
bull Operate if poor hearing or progression over time
bull Balance risks of surgery vs risks of non-intervention
bull Cartilage repair has gained popularity
Perforations
Safe vs Unsafe ears
bull Brain abscess
After cholesteatoma in 46
After mucosal disease in 38
After mod Rad mastoidectomy in 15
Browning GG The Unsafeness of safe ears JLO 1984a 9823-26
Aetiologies of TM Perforations
bull AOM perforation bull Otitis Externa ndash myringitis (fungal) bull CSOM bull Specific Chronic Suppurative Otitis Media TB Actinomyces Syphilis
bull Direct trauma to membrane bull Post ventilation tubes (275 ear 46 child 13 t-tubes)
bull Barotraumatic bull Blast Injury beware implantation
cholesteatoma
Size Matters
bull Conductive Hearing Loss variable 0 ndash 50 dB
bull Larger perforation = larger ABG
bull Low frequencies greatest affected
bull Post frac12 TM ndash transmits low frequency
bull Ant frac12 TM transmits high frequency
Management of TM perforations
bull Conservative ldquoA small perforation is good it acts as a natural ventilation
tuberdquo
Small hole no infections good hearing poor ETD = leave alone
bull Surgical ldquoThe perforation is bad it leads to recurrent ear infections
and restricts water sportsrdquo
Recurrent infections hearing loss other ear good = repair
Management of TM perforations
bull Conservative
bull Swabs + microsuction
bull Keep ear dry (earplugs for swimming)
bull Topical Agents - Ofloxacin or Ciprofloxacin drops + steroids
bull Systemic antibiotics
Management of TM perforations
bull Surgical
ndash Myringoplasty Tympanoplasty
ndash + - Adenoidectomy
Indications for repair of perforation
bull Any Ear with cholesteatoma
bull Not healed spontaneously after 6 months observation
andhellip
bull Recurrent otorrhoea
bull Disabling conductive hearing loss bull Bilateral ( gt30 - 40 dB)
bull Unilateral
bull To allow watersports
Wullstein Classification of Tympanoplasty (1956)
bull Type I ndash Myringoplasty = 3 ossicles present amp drum repair
bull Type II ndash Malleusincus eroded ndash reconstruction preserves middle ear depth
bull Type III ndash Lateral ossicles gone graft onto stapes superstructure columella effect shallow ME cleft
bull Type IV ndash No ossicles graft onto footplate
bull Type V ndash graft onto fixed footplate Va = fenestration of LSSC
Tympoanoplasty Type 1 in children ndash an evaluative study
bull Gautam Bir Sing et al Int J Ped Otorninolaryngol 200569 (8)1071-76
bull 80 graft success rate at 6 month
bull 61 significant improved hearing
Meta-analysis of Pediatric Tympanoplasty
bull Vrabec et al Arch Otolaryngol H amp Neck Surg 1999 125 (5) 530-34
bull Graft take rate 80 in perf less than half TM
69 if over half TM
bull Take rate with good vs poor ET function 87 cf 77
bull Adenoids ndash no difference
bull Normal contralat ear vs abnormal 80 cf 71
bull Wet ear ndash no difference
bull Increased success rate with increasing Age (p =0005)
What Age to perform myringoplasty
bull Success rate not influenced by age (eg House Ear Institute
Chandrasekhar et al Arch Oto HampN Surg 1995 121873-878 and Denoyelle Garabedien group Paris Laryngoscope)
bull Mean age of most paediatric published series = 10 ndash 11 years (range 4 ndash 17)
bull General Advice (GMorrison) ndash Other ear predicts outcome ndash 7 ndash 8 yrs or over if infections controllable and one good
hearing ear ndash As early as 3 ndash 4 if bilat Subtotal perfs with disabling
hearing loss amp infections
Myringoplasty ndash Personal Surgical tips
bull Consider periosteum graft
bull Dry graft thoroughly
bull Trim graft to exact size (little finger nail)
bull Underlay or reverse thru-lay technique
bull ldquoKerrrdquo ant wall pocket if no anterior lip
bull Subcuticular resorbable sutures
bull BIPP pack(s) except v young
EAM
ME
Anterior
Cartilage Tympanoplasty
bull Jansen 1958
bull Heerman 1962 ndash cartilage palisade
bull Techniques
ndash Island graft
ndash Palisades
ndash Butterfly inlay
ndash Cartilage Shield
Indications for Cartilage Tympanoplasty
bull Retraction pockets
bull Atelectasis
bull Poor ET Function
bull To prevent prosthesis extrusion
bull (Revision Surgery)
Reinforcement Tympanoplasty for retraction
Post Cartilage Tympanoplasty amp Incus transposition
Surgical Outcomes for Paediatric Myringoplasty
bull Fat plug Myringoplasty ndash 80 success bull Paper - steristrip myringoplasty ndash 65 bull Formal Myringoplasty - over 80 closure - 60 - 81 hearing
success bull Hearing gain - ABG to lt 10 dB to 23 lt20 dB in 883
Risk of OME after repair ndash 78 Long term graft breakdown ndash 65
Wet Ear Surgery
bull Moist ear ndash OK
bull Purulent Ear ndash Surgery Contraindicated
Conclusions
bull AOM and CSOM without cholesteatoma can lead to intracranial complications
bull Persistent perforations post grommets are seen in up to 46 patients
bull Operate when ET function improved
bull Cartilage Tympanoplasty has advantages in special cases
bull You can routinely repair ears at 8 years
bull Surgery best avoided in a purulent ear
Thank You
Pars tensa Retractions in children by excision and ventilation tubes
bull Srinivasan V et al - Clin Otolaryngol Allied Sci 2000 25(4)253-6
bull 74 TM healing
bull 22 Re-retraction
Cochrane Review ndash Surgery for Tympanic Membrane Retraction Pockets
bull Nankivell PC and Pothier DD
bull 2010
bull 42 studies ndash 2 RCTs
bull Barbara 2008 (attic reconstruction) amp Elsheikh 2006 (pars tensa repair + - T tube)
bull ldquoNo statistical benefit of surgical interventionrdquo
bull ldquoThere is currently no good evidence for the role of any individual surgical intervention for the management of atelectasis of the tympanic membranerdquo
BUT
bull One Year Follow up only
bull No mention of attic retraction even though one paper only concerned this
Pars Tensa retractions - Natural History
bull TARGET trial ndash MISLEADING bull Retractions are spontaneously variable with time and may be reversible
bull Postero-superior retractions lead to 1o acquired
cholesteatomas (Sudhoff HolgerTos Mirko Pathogenesis of Attic Cholesteatoma Clinical
and Immunohistochemical Support for Combination of Retraction Theory and Proliferation Theory American Journal of Otology 2000 21(6)786-792)
Examples Pars Tensa retractions
Pars tensa retraction - What are you going to do
What are you going to do
How do you know if this retraction is going to progress
Grommets for Pars tensa retraction Pockets if under 10 and
bull Stage 1 and hearing loss from OME
bull Stage 2 and hearing loss or GENUINE erosion of LPI noted
bull Stage 3 with HL
bull Atelectasis Stage 4
Strategy for Pars Tensa Retractions
bull Use otoendoscope if limit not seen
bull Younger child ndash Repeated Ventilation tubes of hearing loss
bull Older child ndash consider excision amp grafting
bull Always montior the ME pressure -ve = delay surgery
bull Progressive or unstable poster-superior retraction - Operate
bull If hearing loss ndash offer surgery
bull Decision also depends on status of contralat ear age of patient amp historic
rate of progression
Reconstructive surgery for P tensa retraction if
bull Grade III retraction when adolescent
bull Retraction limits not seen in facial recess sinus tympani and unstable ndash periodic infections
bull Retraction into facial recess sinus tympani amp tympanogram improving
bull Grade IV retraction when adolescent
Mild retractionGood hearing
Pars tensa retraction pocket Atelectasiscollapse
Deep retractionEarly LPI erosion
Good or bad hearing
grommets
Glue earHearing loss
Trial grommets
Unstable retractionLimit of pocket out of view
Ossicular erosion
Reinforcement tympanoplasty+- ossiculoplasty
+- long term ventilation tube
Observation extrudes
Resolved discharge patient
lt10 years gt10 years
Failure
Summary
bull Classifications described
bull Vent Tubes correct Ptensa retractn while in situ
bull Postero-superior pockets can erode ossicles amp develop cholesteatoma
bull Surgery can be preventative or corrective
bull Operate if poor hearing or progression over time
bull Balance risks of surgery vs risks of non-intervention
bull Cartilage repair has gained popularity
Perforations
Safe vs Unsafe ears
bull Brain abscess
After cholesteatoma in 46
After mucosal disease in 38
After mod Rad mastoidectomy in 15
Browning GG The Unsafeness of safe ears JLO 1984a 9823-26
Aetiologies of TM Perforations
bull AOM perforation bull Otitis Externa ndash myringitis (fungal) bull CSOM bull Specific Chronic Suppurative Otitis Media TB Actinomyces Syphilis
bull Direct trauma to membrane bull Post ventilation tubes (275 ear 46 child 13 t-tubes)
bull Barotraumatic bull Blast Injury beware implantation
cholesteatoma
Size Matters
bull Conductive Hearing Loss variable 0 ndash 50 dB
bull Larger perforation = larger ABG
bull Low frequencies greatest affected
bull Post frac12 TM ndash transmits low frequency
bull Ant frac12 TM transmits high frequency
Management of TM perforations
bull Conservative ldquoA small perforation is good it acts as a natural ventilation
tuberdquo
Small hole no infections good hearing poor ETD = leave alone
bull Surgical ldquoThe perforation is bad it leads to recurrent ear infections
and restricts water sportsrdquo
Recurrent infections hearing loss other ear good = repair
Management of TM perforations
bull Conservative
bull Swabs + microsuction
bull Keep ear dry (earplugs for swimming)
bull Topical Agents - Ofloxacin or Ciprofloxacin drops + steroids
bull Systemic antibiotics
Management of TM perforations
bull Surgical
ndash Myringoplasty Tympanoplasty
ndash + - Adenoidectomy
Indications for repair of perforation
bull Any Ear with cholesteatoma
bull Not healed spontaneously after 6 months observation
andhellip
bull Recurrent otorrhoea
bull Disabling conductive hearing loss bull Bilateral ( gt30 - 40 dB)
bull Unilateral
bull To allow watersports
Wullstein Classification of Tympanoplasty (1956)
bull Type I ndash Myringoplasty = 3 ossicles present amp drum repair
bull Type II ndash Malleusincus eroded ndash reconstruction preserves middle ear depth
bull Type III ndash Lateral ossicles gone graft onto stapes superstructure columella effect shallow ME cleft
bull Type IV ndash No ossicles graft onto footplate
bull Type V ndash graft onto fixed footplate Va = fenestration of LSSC
Tympoanoplasty Type 1 in children ndash an evaluative study
bull Gautam Bir Sing et al Int J Ped Otorninolaryngol 200569 (8)1071-76
bull 80 graft success rate at 6 month
bull 61 significant improved hearing
Meta-analysis of Pediatric Tympanoplasty
bull Vrabec et al Arch Otolaryngol H amp Neck Surg 1999 125 (5) 530-34
bull Graft take rate 80 in perf less than half TM
69 if over half TM
bull Take rate with good vs poor ET function 87 cf 77
bull Adenoids ndash no difference
bull Normal contralat ear vs abnormal 80 cf 71
bull Wet ear ndash no difference
bull Increased success rate with increasing Age (p =0005)
What Age to perform myringoplasty
bull Success rate not influenced by age (eg House Ear Institute
Chandrasekhar et al Arch Oto HampN Surg 1995 121873-878 and Denoyelle Garabedien group Paris Laryngoscope)
bull Mean age of most paediatric published series = 10 ndash 11 years (range 4 ndash 17)
bull General Advice (GMorrison) ndash Other ear predicts outcome ndash 7 ndash 8 yrs or over if infections controllable and one good
hearing ear ndash As early as 3 ndash 4 if bilat Subtotal perfs with disabling
hearing loss amp infections
Myringoplasty ndash Personal Surgical tips
bull Consider periosteum graft
bull Dry graft thoroughly
bull Trim graft to exact size (little finger nail)
bull Underlay or reverse thru-lay technique
bull ldquoKerrrdquo ant wall pocket if no anterior lip
bull Subcuticular resorbable sutures
bull BIPP pack(s) except v young
EAM
ME
Anterior
Cartilage Tympanoplasty
bull Jansen 1958
bull Heerman 1962 ndash cartilage palisade
bull Techniques
ndash Island graft
ndash Palisades
ndash Butterfly inlay
ndash Cartilage Shield
Indications for Cartilage Tympanoplasty
bull Retraction pockets
bull Atelectasis
bull Poor ET Function
bull To prevent prosthesis extrusion
bull (Revision Surgery)
Reinforcement Tympanoplasty for retraction
Post Cartilage Tympanoplasty amp Incus transposition
Surgical Outcomes for Paediatric Myringoplasty
bull Fat plug Myringoplasty ndash 80 success bull Paper - steristrip myringoplasty ndash 65 bull Formal Myringoplasty - over 80 closure - 60 - 81 hearing
success bull Hearing gain - ABG to lt 10 dB to 23 lt20 dB in 883
Risk of OME after repair ndash 78 Long term graft breakdown ndash 65
Wet Ear Surgery
bull Moist ear ndash OK
bull Purulent Ear ndash Surgery Contraindicated
Conclusions
bull AOM and CSOM without cholesteatoma can lead to intracranial complications
bull Persistent perforations post grommets are seen in up to 46 patients
bull Operate when ET function improved
bull Cartilage Tympanoplasty has advantages in special cases
bull You can routinely repair ears at 8 years
bull Surgery best avoided in a purulent ear
Thank You
Cochrane Review ndash Surgery for Tympanic Membrane Retraction Pockets
bull Nankivell PC and Pothier DD
bull 2010
bull 42 studies ndash 2 RCTs
bull Barbara 2008 (attic reconstruction) amp Elsheikh 2006 (pars tensa repair + - T tube)
bull ldquoNo statistical benefit of surgical interventionrdquo
bull ldquoThere is currently no good evidence for the role of any individual surgical intervention for the management of atelectasis of the tympanic membranerdquo
BUT
bull One Year Follow up only
bull No mention of attic retraction even though one paper only concerned this
Pars Tensa retractions - Natural History
bull TARGET trial ndash MISLEADING bull Retractions are spontaneously variable with time and may be reversible
bull Postero-superior retractions lead to 1o acquired
cholesteatomas (Sudhoff HolgerTos Mirko Pathogenesis of Attic Cholesteatoma Clinical
and Immunohistochemical Support for Combination of Retraction Theory and Proliferation Theory American Journal of Otology 2000 21(6)786-792)
Examples Pars Tensa retractions
Pars tensa retraction - What are you going to do
What are you going to do
How do you know if this retraction is going to progress
Grommets for Pars tensa retraction Pockets if under 10 and
bull Stage 1 and hearing loss from OME
bull Stage 2 and hearing loss or GENUINE erosion of LPI noted
bull Stage 3 with HL
bull Atelectasis Stage 4
Strategy for Pars Tensa Retractions
bull Use otoendoscope if limit not seen
bull Younger child ndash Repeated Ventilation tubes of hearing loss
bull Older child ndash consider excision amp grafting
bull Always montior the ME pressure -ve = delay surgery
bull Progressive or unstable poster-superior retraction - Operate
bull If hearing loss ndash offer surgery
bull Decision also depends on status of contralat ear age of patient amp historic
rate of progression
Reconstructive surgery for P tensa retraction if
bull Grade III retraction when adolescent
bull Retraction limits not seen in facial recess sinus tympani and unstable ndash periodic infections
bull Retraction into facial recess sinus tympani amp tympanogram improving
bull Grade IV retraction when adolescent
Mild retractionGood hearing
Pars tensa retraction pocket Atelectasiscollapse
Deep retractionEarly LPI erosion
Good or bad hearing
grommets
Glue earHearing loss
Trial grommets
Unstable retractionLimit of pocket out of view
Ossicular erosion
Reinforcement tympanoplasty+- ossiculoplasty
+- long term ventilation tube
Observation extrudes
Resolved discharge patient
lt10 years gt10 years
Failure
Summary
bull Classifications described
bull Vent Tubes correct Ptensa retractn while in situ
bull Postero-superior pockets can erode ossicles amp develop cholesteatoma
bull Surgery can be preventative or corrective
bull Operate if poor hearing or progression over time
bull Balance risks of surgery vs risks of non-intervention
bull Cartilage repair has gained popularity
Perforations
Safe vs Unsafe ears
bull Brain abscess
After cholesteatoma in 46
After mucosal disease in 38
After mod Rad mastoidectomy in 15
Browning GG The Unsafeness of safe ears JLO 1984a 9823-26
Aetiologies of TM Perforations
bull AOM perforation bull Otitis Externa ndash myringitis (fungal) bull CSOM bull Specific Chronic Suppurative Otitis Media TB Actinomyces Syphilis
bull Direct trauma to membrane bull Post ventilation tubes (275 ear 46 child 13 t-tubes)
bull Barotraumatic bull Blast Injury beware implantation
cholesteatoma
Size Matters
bull Conductive Hearing Loss variable 0 ndash 50 dB
bull Larger perforation = larger ABG
bull Low frequencies greatest affected
bull Post frac12 TM ndash transmits low frequency
bull Ant frac12 TM transmits high frequency
Management of TM perforations
bull Conservative ldquoA small perforation is good it acts as a natural ventilation
tuberdquo
Small hole no infections good hearing poor ETD = leave alone
bull Surgical ldquoThe perforation is bad it leads to recurrent ear infections
and restricts water sportsrdquo
Recurrent infections hearing loss other ear good = repair
Management of TM perforations
bull Conservative
bull Swabs + microsuction
bull Keep ear dry (earplugs for swimming)
bull Topical Agents - Ofloxacin or Ciprofloxacin drops + steroids
bull Systemic antibiotics
Management of TM perforations
bull Surgical
ndash Myringoplasty Tympanoplasty
ndash + - Adenoidectomy
Indications for repair of perforation
bull Any Ear with cholesteatoma
bull Not healed spontaneously after 6 months observation
andhellip
bull Recurrent otorrhoea
bull Disabling conductive hearing loss bull Bilateral ( gt30 - 40 dB)
bull Unilateral
bull To allow watersports
Wullstein Classification of Tympanoplasty (1956)
bull Type I ndash Myringoplasty = 3 ossicles present amp drum repair
bull Type II ndash Malleusincus eroded ndash reconstruction preserves middle ear depth
bull Type III ndash Lateral ossicles gone graft onto stapes superstructure columella effect shallow ME cleft
bull Type IV ndash No ossicles graft onto footplate
bull Type V ndash graft onto fixed footplate Va = fenestration of LSSC
Tympoanoplasty Type 1 in children ndash an evaluative study
bull Gautam Bir Sing et al Int J Ped Otorninolaryngol 200569 (8)1071-76
bull 80 graft success rate at 6 month
bull 61 significant improved hearing
Meta-analysis of Pediatric Tympanoplasty
bull Vrabec et al Arch Otolaryngol H amp Neck Surg 1999 125 (5) 530-34
bull Graft take rate 80 in perf less than half TM
69 if over half TM
bull Take rate with good vs poor ET function 87 cf 77
bull Adenoids ndash no difference
bull Normal contralat ear vs abnormal 80 cf 71
bull Wet ear ndash no difference
bull Increased success rate with increasing Age (p =0005)
What Age to perform myringoplasty
bull Success rate not influenced by age (eg House Ear Institute
Chandrasekhar et al Arch Oto HampN Surg 1995 121873-878 and Denoyelle Garabedien group Paris Laryngoscope)
bull Mean age of most paediatric published series = 10 ndash 11 years (range 4 ndash 17)
bull General Advice (GMorrison) ndash Other ear predicts outcome ndash 7 ndash 8 yrs or over if infections controllable and one good
hearing ear ndash As early as 3 ndash 4 if bilat Subtotal perfs with disabling
hearing loss amp infections
Myringoplasty ndash Personal Surgical tips
bull Consider periosteum graft
bull Dry graft thoroughly
bull Trim graft to exact size (little finger nail)
bull Underlay or reverse thru-lay technique
bull ldquoKerrrdquo ant wall pocket if no anterior lip
bull Subcuticular resorbable sutures
bull BIPP pack(s) except v young
EAM
ME
Anterior
Cartilage Tympanoplasty
bull Jansen 1958
bull Heerman 1962 ndash cartilage palisade
bull Techniques
ndash Island graft
ndash Palisades
ndash Butterfly inlay
ndash Cartilage Shield
Indications for Cartilage Tympanoplasty
bull Retraction pockets
bull Atelectasis
bull Poor ET Function
bull To prevent prosthesis extrusion
bull (Revision Surgery)
Reinforcement Tympanoplasty for retraction
Post Cartilage Tympanoplasty amp Incus transposition
Surgical Outcomes for Paediatric Myringoplasty
bull Fat plug Myringoplasty ndash 80 success bull Paper - steristrip myringoplasty ndash 65 bull Formal Myringoplasty - over 80 closure - 60 - 81 hearing
success bull Hearing gain - ABG to lt 10 dB to 23 lt20 dB in 883
Risk of OME after repair ndash 78 Long term graft breakdown ndash 65
Wet Ear Surgery
bull Moist ear ndash OK
bull Purulent Ear ndash Surgery Contraindicated
Conclusions
bull AOM and CSOM without cholesteatoma can lead to intracranial complications
bull Persistent perforations post grommets are seen in up to 46 patients
bull Operate when ET function improved
bull Cartilage Tympanoplasty has advantages in special cases
bull You can routinely repair ears at 8 years
bull Surgery best avoided in a purulent ear
Thank You
bull ldquoThere is currently no good evidence for the role of any individual surgical intervention for the management of atelectasis of the tympanic membranerdquo
BUT
bull One Year Follow up only
bull No mention of attic retraction even though one paper only concerned this
Pars Tensa retractions - Natural History
bull TARGET trial ndash MISLEADING bull Retractions are spontaneously variable with time and may be reversible
bull Postero-superior retractions lead to 1o acquired
cholesteatomas (Sudhoff HolgerTos Mirko Pathogenesis of Attic Cholesteatoma Clinical
and Immunohistochemical Support for Combination of Retraction Theory and Proliferation Theory American Journal of Otology 2000 21(6)786-792)
Examples Pars Tensa retractions
Pars tensa retraction - What are you going to do
What are you going to do
How do you know if this retraction is going to progress
Grommets for Pars tensa retraction Pockets if under 10 and
bull Stage 1 and hearing loss from OME
bull Stage 2 and hearing loss or GENUINE erosion of LPI noted
bull Stage 3 with HL
bull Atelectasis Stage 4
Strategy for Pars Tensa Retractions
bull Use otoendoscope if limit not seen
bull Younger child ndash Repeated Ventilation tubes of hearing loss
bull Older child ndash consider excision amp grafting
bull Always montior the ME pressure -ve = delay surgery
bull Progressive or unstable poster-superior retraction - Operate
bull If hearing loss ndash offer surgery
bull Decision also depends on status of contralat ear age of patient amp historic
rate of progression
Reconstructive surgery for P tensa retraction if
bull Grade III retraction when adolescent
bull Retraction limits not seen in facial recess sinus tympani and unstable ndash periodic infections
bull Retraction into facial recess sinus tympani amp tympanogram improving
bull Grade IV retraction when adolescent
Mild retractionGood hearing
Pars tensa retraction pocket Atelectasiscollapse
Deep retractionEarly LPI erosion
Good or bad hearing
grommets
Glue earHearing loss
Trial grommets
Unstable retractionLimit of pocket out of view
Ossicular erosion
Reinforcement tympanoplasty+- ossiculoplasty
+- long term ventilation tube
Observation extrudes
Resolved discharge patient
lt10 years gt10 years
Failure
Summary
bull Classifications described
bull Vent Tubes correct Ptensa retractn while in situ
bull Postero-superior pockets can erode ossicles amp develop cholesteatoma
bull Surgery can be preventative or corrective
bull Operate if poor hearing or progression over time
bull Balance risks of surgery vs risks of non-intervention
bull Cartilage repair has gained popularity
Perforations
Safe vs Unsafe ears
bull Brain abscess
After cholesteatoma in 46
After mucosal disease in 38
After mod Rad mastoidectomy in 15
Browning GG The Unsafeness of safe ears JLO 1984a 9823-26
Aetiologies of TM Perforations
bull AOM perforation bull Otitis Externa ndash myringitis (fungal) bull CSOM bull Specific Chronic Suppurative Otitis Media TB Actinomyces Syphilis
bull Direct trauma to membrane bull Post ventilation tubes (275 ear 46 child 13 t-tubes)
bull Barotraumatic bull Blast Injury beware implantation
cholesteatoma
Size Matters
bull Conductive Hearing Loss variable 0 ndash 50 dB
bull Larger perforation = larger ABG
bull Low frequencies greatest affected
bull Post frac12 TM ndash transmits low frequency
bull Ant frac12 TM transmits high frequency
Management of TM perforations
bull Conservative ldquoA small perforation is good it acts as a natural ventilation
tuberdquo
Small hole no infections good hearing poor ETD = leave alone
bull Surgical ldquoThe perforation is bad it leads to recurrent ear infections
and restricts water sportsrdquo
Recurrent infections hearing loss other ear good = repair
Management of TM perforations
bull Conservative
bull Swabs + microsuction
bull Keep ear dry (earplugs for swimming)
bull Topical Agents - Ofloxacin or Ciprofloxacin drops + steroids
bull Systemic antibiotics
Management of TM perforations
bull Surgical
ndash Myringoplasty Tympanoplasty
ndash + - Adenoidectomy
Indications for repair of perforation
bull Any Ear with cholesteatoma
bull Not healed spontaneously after 6 months observation
andhellip
bull Recurrent otorrhoea
bull Disabling conductive hearing loss bull Bilateral ( gt30 - 40 dB)
bull Unilateral
bull To allow watersports
Wullstein Classification of Tympanoplasty (1956)
bull Type I ndash Myringoplasty = 3 ossicles present amp drum repair
bull Type II ndash Malleusincus eroded ndash reconstruction preserves middle ear depth
bull Type III ndash Lateral ossicles gone graft onto stapes superstructure columella effect shallow ME cleft
bull Type IV ndash No ossicles graft onto footplate
bull Type V ndash graft onto fixed footplate Va = fenestration of LSSC
Tympoanoplasty Type 1 in children ndash an evaluative study
bull Gautam Bir Sing et al Int J Ped Otorninolaryngol 200569 (8)1071-76
bull 80 graft success rate at 6 month
bull 61 significant improved hearing
Meta-analysis of Pediatric Tympanoplasty
bull Vrabec et al Arch Otolaryngol H amp Neck Surg 1999 125 (5) 530-34
bull Graft take rate 80 in perf less than half TM
69 if over half TM
bull Take rate with good vs poor ET function 87 cf 77
bull Adenoids ndash no difference
bull Normal contralat ear vs abnormal 80 cf 71
bull Wet ear ndash no difference
bull Increased success rate with increasing Age (p =0005)
What Age to perform myringoplasty
bull Success rate not influenced by age (eg House Ear Institute
Chandrasekhar et al Arch Oto HampN Surg 1995 121873-878 and Denoyelle Garabedien group Paris Laryngoscope)
bull Mean age of most paediatric published series = 10 ndash 11 years (range 4 ndash 17)
bull General Advice (GMorrison) ndash Other ear predicts outcome ndash 7 ndash 8 yrs or over if infections controllable and one good
hearing ear ndash As early as 3 ndash 4 if bilat Subtotal perfs with disabling
hearing loss amp infections
Myringoplasty ndash Personal Surgical tips
bull Consider periosteum graft
bull Dry graft thoroughly
bull Trim graft to exact size (little finger nail)
bull Underlay or reverse thru-lay technique
bull ldquoKerrrdquo ant wall pocket if no anterior lip
bull Subcuticular resorbable sutures
bull BIPP pack(s) except v young
EAM
ME
Anterior
Cartilage Tympanoplasty
bull Jansen 1958
bull Heerman 1962 ndash cartilage palisade
bull Techniques
ndash Island graft
ndash Palisades
ndash Butterfly inlay
ndash Cartilage Shield
Indications for Cartilage Tympanoplasty
bull Retraction pockets
bull Atelectasis
bull Poor ET Function
bull To prevent prosthesis extrusion
bull (Revision Surgery)
Reinforcement Tympanoplasty for retraction
Post Cartilage Tympanoplasty amp Incus transposition
Surgical Outcomes for Paediatric Myringoplasty
bull Fat plug Myringoplasty ndash 80 success bull Paper - steristrip myringoplasty ndash 65 bull Formal Myringoplasty - over 80 closure - 60 - 81 hearing
success bull Hearing gain - ABG to lt 10 dB to 23 lt20 dB in 883
Risk of OME after repair ndash 78 Long term graft breakdown ndash 65
Wet Ear Surgery
bull Moist ear ndash OK
bull Purulent Ear ndash Surgery Contraindicated
Conclusions
bull AOM and CSOM without cholesteatoma can lead to intracranial complications
bull Persistent perforations post grommets are seen in up to 46 patients
bull Operate when ET function improved
bull Cartilage Tympanoplasty has advantages in special cases
bull You can routinely repair ears at 8 years
bull Surgery best avoided in a purulent ear
Thank You
Pars Tensa retractions - Natural History
bull TARGET trial ndash MISLEADING bull Retractions are spontaneously variable with time and may be reversible
bull Postero-superior retractions lead to 1o acquired
cholesteatomas (Sudhoff HolgerTos Mirko Pathogenesis of Attic Cholesteatoma Clinical
and Immunohistochemical Support for Combination of Retraction Theory and Proliferation Theory American Journal of Otology 2000 21(6)786-792)
Examples Pars Tensa retractions
Pars tensa retraction - What are you going to do
What are you going to do
How do you know if this retraction is going to progress
Grommets for Pars tensa retraction Pockets if under 10 and
bull Stage 1 and hearing loss from OME
bull Stage 2 and hearing loss or GENUINE erosion of LPI noted
bull Stage 3 with HL
bull Atelectasis Stage 4
Strategy for Pars Tensa Retractions
bull Use otoendoscope if limit not seen
bull Younger child ndash Repeated Ventilation tubes of hearing loss
bull Older child ndash consider excision amp grafting
bull Always montior the ME pressure -ve = delay surgery
bull Progressive or unstable poster-superior retraction - Operate
bull If hearing loss ndash offer surgery
bull Decision also depends on status of contralat ear age of patient amp historic
rate of progression
Reconstructive surgery for P tensa retraction if
bull Grade III retraction when adolescent
bull Retraction limits not seen in facial recess sinus tympani and unstable ndash periodic infections
bull Retraction into facial recess sinus tympani amp tympanogram improving
bull Grade IV retraction when adolescent
Mild retractionGood hearing
Pars tensa retraction pocket Atelectasiscollapse
Deep retractionEarly LPI erosion
Good or bad hearing
grommets
Glue earHearing loss
Trial grommets
Unstable retractionLimit of pocket out of view
Ossicular erosion
Reinforcement tympanoplasty+- ossiculoplasty
+- long term ventilation tube
Observation extrudes
Resolved discharge patient
lt10 years gt10 years
Failure
Summary
bull Classifications described
bull Vent Tubes correct Ptensa retractn while in situ
bull Postero-superior pockets can erode ossicles amp develop cholesteatoma
bull Surgery can be preventative or corrective
bull Operate if poor hearing or progression over time
bull Balance risks of surgery vs risks of non-intervention
bull Cartilage repair has gained popularity
Perforations
Safe vs Unsafe ears
bull Brain abscess
After cholesteatoma in 46
After mucosal disease in 38
After mod Rad mastoidectomy in 15
Browning GG The Unsafeness of safe ears JLO 1984a 9823-26
Aetiologies of TM Perforations
bull AOM perforation bull Otitis Externa ndash myringitis (fungal) bull CSOM bull Specific Chronic Suppurative Otitis Media TB Actinomyces Syphilis
bull Direct trauma to membrane bull Post ventilation tubes (275 ear 46 child 13 t-tubes)
bull Barotraumatic bull Blast Injury beware implantation
cholesteatoma
Size Matters
bull Conductive Hearing Loss variable 0 ndash 50 dB
bull Larger perforation = larger ABG
bull Low frequencies greatest affected
bull Post frac12 TM ndash transmits low frequency
bull Ant frac12 TM transmits high frequency
Management of TM perforations
bull Conservative ldquoA small perforation is good it acts as a natural ventilation
tuberdquo
Small hole no infections good hearing poor ETD = leave alone
bull Surgical ldquoThe perforation is bad it leads to recurrent ear infections
and restricts water sportsrdquo
Recurrent infections hearing loss other ear good = repair
Management of TM perforations
bull Conservative
bull Swabs + microsuction
bull Keep ear dry (earplugs for swimming)
bull Topical Agents - Ofloxacin or Ciprofloxacin drops + steroids
bull Systemic antibiotics
Management of TM perforations
bull Surgical
ndash Myringoplasty Tympanoplasty
ndash + - Adenoidectomy
Indications for repair of perforation
bull Any Ear with cholesteatoma
bull Not healed spontaneously after 6 months observation
andhellip
bull Recurrent otorrhoea
bull Disabling conductive hearing loss bull Bilateral ( gt30 - 40 dB)
bull Unilateral
bull To allow watersports
Wullstein Classification of Tympanoplasty (1956)
bull Type I ndash Myringoplasty = 3 ossicles present amp drum repair
bull Type II ndash Malleusincus eroded ndash reconstruction preserves middle ear depth
bull Type III ndash Lateral ossicles gone graft onto stapes superstructure columella effect shallow ME cleft
bull Type IV ndash No ossicles graft onto footplate
bull Type V ndash graft onto fixed footplate Va = fenestration of LSSC
Tympoanoplasty Type 1 in children ndash an evaluative study
bull Gautam Bir Sing et al Int J Ped Otorninolaryngol 200569 (8)1071-76
bull 80 graft success rate at 6 month
bull 61 significant improved hearing
Meta-analysis of Pediatric Tympanoplasty
bull Vrabec et al Arch Otolaryngol H amp Neck Surg 1999 125 (5) 530-34
bull Graft take rate 80 in perf less than half TM
69 if over half TM
bull Take rate with good vs poor ET function 87 cf 77
bull Adenoids ndash no difference
bull Normal contralat ear vs abnormal 80 cf 71
bull Wet ear ndash no difference
bull Increased success rate with increasing Age (p =0005)
What Age to perform myringoplasty
bull Success rate not influenced by age (eg House Ear Institute
Chandrasekhar et al Arch Oto HampN Surg 1995 121873-878 and Denoyelle Garabedien group Paris Laryngoscope)
bull Mean age of most paediatric published series = 10 ndash 11 years (range 4 ndash 17)
bull General Advice (GMorrison) ndash Other ear predicts outcome ndash 7 ndash 8 yrs or over if infections controllable and one good
hearing ear ndash As early as 3 ndash 4 if bilat Subtotal perfs with disabling
hearing loss amp infections
Myringoplasty ndash Personal Surgical tips
bull Consider periosteum graft
bull Dry graft thoroughly
bull Trim graft to exact size (little finger nail)
bull Underlay or reverse thru-lay technique
bull ldquoKerrrdquo ant wall pocket if no anterior lip
bull Subcuticular resorbable sutures
bull BIPP pack(s) except v young
EAM
ME
Anterior
Cartilage Tympanoplasty
bull Jansen 1958
bull Heerman 1962 ndash cartilage palisade
bull Techniques
ndash Island graft
ndash Palisades
ndash Butterfly inlay
ndash Cartilage Shield
Indications for Cartilage Tympanoplasty
bull Retraction pockets
bull Atelectasis
bull Poor ET Function
bull To prevent prosthesis extrusion
bull (Revision Surgery)
Reinforcement Tympanoplasty for retraction
Post Cartilage Tympanoplasty amp Incus transposition
Surgical Outcomes for Paediatric Myringoplasty
bull Fat plug Myringoplasty ndash 80 success bull Paper - steristrip myringoplasty ndash 65 bull Formal Myringoplasty - over 80 closure - 60 - 81 hearing
success bull Hearing gain - ABG to lt 10 dB to 23 lt20 dB in 883
Risk of OME after repair ndash 78 Long term graft breakdown ndash 65
Wet Ear Surgery
bull Moist ear ndash OK
bull Purulent Ear ndash Surgery Contraindicated
Conclusions
bull AOM and CSOM without cholesteatoma can lead to intracranial complications
bull Persistent perforations post grommets are seen in up to 46 patients
bull Operate when ET function improved
bull Cartilage Tympanoplasty has advantages in special cases
bull You can routinely repair ears at 8 years
bull Surgery best avoided in a purulent ear
Thank You
Examples Pars Tensa retractions
Pars tensa retraction - What are you going to do
What are you going to do
How do you know if this retraction is going to progress
Grommets for Pars tensa retraction Pockets if under 10 and
bull Stage 1 and hearing loss from OME
bull Stage 2 and hearing loss or GENUINE erosion of LPI noted
bull Stage 3 with HL
bull Atelectasis Stage 4
Strategy for Pars Tensa Retractions
bull Use otoendoscope if limit not seen
bull Younger child ndash Repeated Ventilation tubes of hearing loss
bull Older child ndash consider excision amp grafting
bull Always montior the ME pressure -ve = delay surgery
bull Progressive or unstable poster-superior retraction - Operate
bull If hearing loss ndash offer surgery
bull Decision also depends on status of contralat ear age of patient amp historic
rate of progression
Reconstructive surgery for P tensa retraction if
bull Grade III retraction when adolescent
bull Retraction limits not seen in facial recess sinus tympani and unstable ndash periodic infections
bull Retraction into facial recess sinus tympani amp tympanogram improving
bull Grade IV retraction when adolescent
Mild retractionGood hearing
Pars tensa retraction pocket Atelectasiscollapse
Deep retractionEarly LPI erosion
Good or bad hearing
grommets
Glue earHearing loss
Trial grommets
Unstable retractionLimit of pocket out of view
Ossicular erosion
Reinforcement tympanoplasty+- ossiculoplasty
+- long term ventilation tube
Observation extrudes
Resolved discharge patient
lt10 years gt10 years
Failure
Summary
bull Classifications described
bull Vent Tubes correct Ptensa retractn while in situ
bull Postero-superior pockets can erode ossicles amp develop cholesteatoma
bull Surgery can be preventative or corrective
bull Operate if poor hearing or progression over time
bull Balance risks of surgery vs risks of non-intervention
bull Cartilage repair has gained popularity
Perforations
Safe vs Unsafe ears
bull Brain abscess
After cholesteatoma in 46
After mucosal disease in 38
After mod Rad mastoidectomy in 15
Browning GG The Unsafeness of safe ears JLO 1984a 9823-26
Aetiologies of TM Perforations
bull AOM perforation bull Otitis Externa ndash myringitis (fungal) bull CSOM bull Specific Chronic Suppurative Otitis Media TB Actinomyces Syphilis
bull Direct trauma to membrane bull Post ventilation tubes (275 ear 46 child 13 t-tubes)
bull Barotraumatic bull Blast Injury beware implantation
cholesteatoma
Size Matters
bull Conductive Hearing Loss variable 0 ndash 50 dB
bull Larger perforation = larger ABG
bull Low frequencies greatest affected
bull Post frac12 TM ndash transmits low frequency
bull Ant frac12 TM transmits high frequency
Management of TM perforations
bull Conservative ldquoA small perforation is good it acts as a natural ventilation
tuberdquo
Small hole no infections good hearing poor ETD = leave alone
bull Surgical ldquoThe perforation is bad it leads to recurrent ear infections
and restricts water sportsrdquo
Recurrent infections hearing loss other ear good = repair
Management of TM perforations
bull Conservative
bull Swabs + microsuction
bull Keep ear dry (earplugs for swimming)
bull Topical Agents - Ofloxacin or Ciprofloxacin drops + steroids
bull Systemic antibiotics
Management of TM perforations
bull Surgical
ndash Myringoplasty Tympanoplasty
ndash + - Adenoidectomy
Indications for repair of perforation
bull Any Ear with cholesteatoma
bull Not healed spontaneously after 6 months observation
andhellip
bull Recurrent otorrhoea
bull Disabling conductive hearing loss bull Bilateral ( gt30 - 40 dB)
bull Unilateral
bull To allow watersports
Wullstein Classification of Tympanoplasty (1956)
bull Type I ndash Myringoplasty = 3 ossicles present amp drum repair
bull Type II ndash Malleusincus eroded ndash reconstruction preserves middle ear depth
bull Type III ndash Lateral ossicles gone graft onto stapes superstructure columella effect shallow ME cleft
bull Type IV ndash No ossicles graft onto footplate
bull Type V ndash graft onto fixed footplate Va = fenestration of LSSC
Tympoanoplasty Type 1 in children ndash an evaluative study
bull Gautam Bir Sing et al Int J Ped Otorninolaryngol 200569 (8)1071-76
bull 80 graft success rate at 6 month
bull 61 significant improved hearing
Meta-analysis of Pediatric Tympanoplasty
bull Vrabec et al Arch Otolaryngol H amp Neck Surg 1999 125 (5) 530-34
bull Graft take rate 80 in perf less than half TM
69 if over half TM
bull Take rate with good vs poor ET function 87 cf 77
bull Adenoids ndash no difference
bull Normal contralat ear vs abnormal 80 cf 71
bull Wet ear ndash no difference
bull Increased success rate with increasing Age (p =0005)
What Age to perform myringoplasty
bull Success rate not influenced by age (eg House Ear Institute
Chandrasekhar et al Arch Oto HampN Surg 1995 121873-878 and Denoyelle Garabedien group Paris Laryngoscope)
bull Mean age of most paediatric published series = 10 ndash 11 years (range 4 ndash 17)
bull General Advice (GMorrison) ndash Other ear predicts outcome ndash 7 ndash 8 yrs or over if infections controllable and one good
hearing ear ndash As early as 3 ndash 4 if bilat Subtotal perfs with disabling
hearing loss amp infections
Myringoplasty ndash Personal Surgical tips
bull Consider periosteum graft
bull Dry graft thoroughly
bull Trim graft to exact size (little finger nail)
bull Underlay or reverse thru-lay technique
bull ldquoKerrrdquo ant wall pocket if no anterior lip
bull Subcuticular resorbable sutures
bull BIPP pack(s) except v young
EAM
ME
Anterior
Cartilage Tympanoplasty
bull Jansen 1958
bull Heerman 1962 ndash cartilage palisade
bull Techniques
ndash Island graft
ndash Palisades
ndash Butterfly inlay
ndash Cartilage Shield
Indications for Cartilage Tympanoplasty
bull Retraction pockets
bull Atelectasis
bull Poor ET Function
bull To prevent prosthesis extrusion
bull (Revision Surgery)
Reinforcement Tympanoplasty for retraction
Post Cartilage Tympanoplasty amp Incus transposition
Surgical Outcomes for Paediatric Myringoplasty
bull Fat plug Myringoplasty ndash 80 success bull Paper - steristrip myringoplasty ndash 65 bull Formal Myringoplasty - over 80 closure - 60 - 81 hearing
success bull Hearing gain - ABG to lt 10 dB to 23 lt20 dB in 883
Risk of OME after repair ndash 78 Long term graft breakdown ndash 65
Wet Ear Surgery
bull Moist ear ndash OK
bull Purulent Ear ndash Surgery Contraindicated
Conclusions
bull AOM and CSOM without cholesteatoma can lead to intracranial complications
bull Persistent perforations post grommets are seen in up to 46 patients
bull Operate when ET function improved
bull Cartilage Tympanoplasty has advantages in special cases
bull You can routinely repair ears at 8 years
bull Surgery best avoided in a purulent ear
Thank You
Pars tensa retraction - What are you going to do
What are you going to do
How do you know if this retraction is going to progress
Grommets for Pars tensa retraction Pockets if under 10 and
bull Stage 1 and hearing loss from OME
bull Stage 2 and hearing loss or GENUINE erosion of LPI noted
bull Stage 3 with HL
bull Atelectasis Stage 4
Strategy for Pars Tensa Retractions
bull Use otoendoscope if limit not seen
bull Younger child ndash Repeated Ventilation tubes of hearing loss
bull Older child ndash consider excision amp grafting
bull Always montior the ME pressure -ve = delay surgery
bull Progressive or unstable poster-superior retraction - Operate
bull If hearing loss ndash offer surgery
bull Decision also depends on status of contralat ear age of patient amp historic
rate of progression
Reconstructive surgery for P tensa retraction if
bull Grade III retraction when adolescent
bull Retraction limits not seen in facial recess sinus tympani and unstable ndash periodic infections
bull Retraction into facial recess sinus tympani amp tympanogram improving
bull Grade IV retraction when adolescent
Mild retractionGood hearing
Pars tensa retraction pocket Atelectasiscollapse
Deep retractionEarly LPI erosion
Good or bad hearing
grommets
Glue earHearing loss
Trial grommets
Unstable retractionLimit of pocket out of view
Ossicular erosion
Reinforcement tympanoplasty+- ossiculoplasty
+- long term ventilation tube
Observation extrudes
Resolved discharge patient
lt10 years gt10 years
Failure
Summary
bull Classifications described
bull Vent Tubes correct Ptensa retractn while in situ
bull Postero-superior pockets can erode ossicles amp develop cholesteatoma
bull Surgery can be preventative or corrective
bull Operate if poor hearing or progression over time
bull Balance risks of surgery vs risks of non-intervention
bull Cartilage repair has gained popularity
Perforations
Safe vs Unsafe ears
bull Brain abscess
After cholesteatoma in 46
After mucosal disease in 38
After mod Rad mastoidectomy in 15
Browning GG The Unsafeness of safe ears JLO 1984a 9823-26
Aetiologies of TM Perforations
bull AOM perforation bull Otitis Externa ndash myringitis (fungal) bull CSOM bull Specific Chronic Suppurative Otitis Media TB Actinomyces Syphilis
bull Direct trauma to membrane bull Post ventilation tubes (275 ear 46 child 13 t-tubes)
bull Barotraumatic bull Blast Injury beware implantation
cholesteatoma
Size Matters
bull Conductive Hearing Loss variable 0 ndash 50 dB
bull Larger perforation = larger ABG
bull Low frequencies greatest affected
bull Post frac12 TM ndash transmits low frequency
bull Ant frac12 TM transmits high frequency
Management of TM perforations
bull Conservative ldquoA small perforation is good it acts as a natural ventilation
tuberdquo
Small hole no infections good hearing poor ETD = leave alone
bull Surgical ldquoThe perforation is bad it leads to recurrent ear infections
and restricts water sportsrdquo
Recurrent infections hearing loss other ear good = repair
Management of TM perforations
bull Conservative
bull Swabs + microsuction
bull Keep ear dry (earplugs for swimming)
bull Topical Agents - Ofloxacin or Ciprofloxacin drops + steroids
bull Systemic antibiotics
Management of TM perforations
bull Surgical
ndash Myringoplasty Tympanoplasty
ndash + - Adenoidectomy
Indications for repair of perforation
bull Any Ear with cholesteatoma
bull Not healed spontaneously after 6 months observation
andhellip
bull Recurrent otorrhoea
bull Disabling conductive hearing loss bull Bilateral ( gt30 - 40 dB)
bull Unilateral
bull To allow watersports
Wullstein Classification of Tympanoplasty (1956)
bull Type I ndash Myringoplasty = 3 ossicles present amp drum repair
bull Type II ndash Malleusincus eroded ndash reconstruction preserves middle ear depth
bull Type III ndash Lateral ossicles gone graft onto stapes superstructure columella effect shallow ME cleft
bull Type IV ndash No ossicles graft onto footplate
bull Type V ndash graft onto fixed footplate Va = fenestration of LSSC
Tympoanoplasty Type 1 in children ndash an evaluative study
bull Gautam Bir Sing et al Int J Ped Otorninolaryngol 200569 (8)1071-76
bull 80 graft success rate at 6 month
bull 61 significant improved hearing
Meta-analysis of Pediatric Tympanoplasty
bull Vrabec et al Arch Otolaryngol H amp Neck Surg 1999 125 (5) 530-34
bull Graft take rate 80 in perf less than half TM
69 if over half TM
bull Take rate with good vs poor ET function 87 cf 77
bull Adenoids ndash no difference
bull Normal contralat ear vs abnormal 80 cf 71
bull Wet ear ndash no difference
bull Increased success rate with increasing Age (p =0005)
What Age to perform myringoplasty
bull Success rate not influenced by age (eg House Ear Institute
Chandrasekhar et al Arch Oto HampN Surg 1995 121873-878 and Denoyelle Garabedien group Paris Laryngoscope)
bull Mean age of most paediatric published series = 10 ndash 11 years (range 4 ndash 17)
bull General Advice (GMorrison) ndash Other ear predicts outcome ndash 7 ndash 8 yrs or over if infections controllable and one good
hearing ear ndash As early as 3 ndash 4 if bilat Subtotal perfs with disabling
hearing loss amp infections
Myringoplasty ndash Personal Surgical tips
bull Consider periosteum graft
bull Dry graft thoroughly
bull Trim graft to exact size (little finger nail)
bull Underlay or reverse thru-lay technique
bull ldquoKerrrdquo ant wall pocket if no anterior lip
bull Subcuticular resorbable sutures
bull BIPP pack(s) except v young
EAM
ME
Anterior
Cartilage Tympanoplasty
bull Jansen 1958
bull Heerman 1962 ndash cartilage palisade
bull Techniques
ndash Island graft
ndash Palisades
ndash Butterfly inlay
ndash Cartilage Shield
Indications for Cartilage Tympanoplasty
bull Retraction pockets
bull Atelectasis
bull Poor ET Function
bull To prevent prosthesis extrusion
bull (Revision Surgery)
Reinforcement Tympanoplasty for retraction
Post Cartilage Tympanoplasty amp Incus transposition
Surgical Outcomes for Paediatric Myringoplasty
bull Fat plug Myringoplasty ndash 80 success bull Paper - steristrip myringoplasty ndash 65 bull Formal Myringoplasty - over 80 closure - 60 - 81 hearing
success bull Hearing gain - ABG to lt 10 dB to 23 lt20 dB in 883
Risk of OME after repair ndash 78 Long term graft breakdown ndash 65
Wet Ear Surgery
bull Moist ear ndash OK
bull Purulent Ear ndash Surgery Contraindicated
Conclusions
bull AOM and CSOM without cholesteatoma can lead to intracranial complications
bull Persistent perforations post grommets are seen in up to 46 patients
bull Operate when ET function improved
bull Cartilage Tympanoplasty has advantages in special cases
bull You can routinely repair ears at 8 years
bull Surgery best avoided in a purulent ear
Thank You
What are you going to do
How do you know if this retraction is going to progress
Grommets for Pars tensa retraction Pockets if under 10 and
bull Stage 1 and hearing loss from OME
bull Stage 2 and hearing loss or GENUINE erosion of LPI noted
bull Stage 3 with HL
bull Atelectasis Stage 4
Strategy for Pars Tensa Retractions
bull Use otoendoscope if limit not seen
bull Younger child ndash Repeated Ventilation tubes of hearing loss
bull Older child ndash consider excision amp grafting
bull Always montior the ME pressure -ve = delay surgery
bull Progressive or unstable poster-superior retraction - Operate
bull If hearing loss ndash offer surgery
bull Decision also depends on status of contralat ear age of patient amp historic
rate of progression
Reconstructive surgery for P tensa retraction if
bull Grade III retraction when adolescent
bull Retraction limits not seen in facial recess sinus tympani and unstable ndash periodic infections
bull Retraction into facial recess sinus tympani amp tympanogram improving
bull Grade IV retraction when adolescent
Mild retractionGood hearing
Pars tensa retraction pocket Atelectasiscollapse
Deep retractionEarly LPI erosion
Good or bad hearing
grommets
Glue earHearing loss
Trial grommets
Unstable retractionLimit of pocket out of view
Ossicular erosion
Reinforcement tympanoplasty+- ossiculoplasty
+- long term ventilation tube
Observation extrudes
Resolved discharge patient
lt10 years gt10 years
Failure
Summary
bull Classifications described
bull Vent Tubes correct Ptensa retractn while in situ
bull Postero-superior pockets can erode ossicles amp develop cholesteatoma
bull Surgery can be preventative or corrective
bull Operate if poor hearing or progression over time
bull Balance risks of surgery vs risks of non-intervention
bull Cartilage repair has gained popularity
Perforations
Safe vs Unsafe ears
bull Brain abscess
After cholesteatoma in 46
After mucosal disease in 38
After mod Rad mastoidectomy in 15
Browning GG The Unsafeness of safe ears JLO 1984a 9823-26
Aetiologies of TM Perforations
bull AOM perforation bull Otitis Externa ndash myringitis (fungal) bull CSOM bull Specific Chronic Suppurative Otitis Media TB Actinomyces Syphilis
bull Direct trauma to membrane bull Post ventilation tubes (275 ear 46 child 13 t-tubes)
bull Barotraumatic bull Blast Injury beware implantation
cholesteatoma
Size Matters
bull Conductive Hearing Loss variable 0 ndash 50 dB
bull Larger perforation = larger ABG
bull Low frequencies greatest affected
bull Post frac12 TM ndash transmits low frequency
bull Ant frac12 TM transmits high frequency
Management of TM perforations
bull Conservative ldquoA small perforation is good it acts as a natural ventilation
tuberdquo
Small hole no infections good hearing poor ETD = leave alone
bull Surgical ldquoThe perforation is bad it leads to recurrent ear infections
and restricts water sportsrdquo
Recurrent infections hearing loss other ear good = repair
Management of TM perforations
bull Conservative
bull Swabs + microsuction
bull Keep ear dry (earplugs for swimming)
bull Topical Agents - Ofloxacin or Ciprofloxacin drops + steroids
bull Systemic antibiotics
Management of TM perforations
bull Surgical
ndash Myringoplasty Tympanoplasty
ndash + - Adenoidectomy
Indications for repair of perforation
bull Any Ear with cholesteatoma
bull Not healed spontaneously after 6 months observation
andhellip
bull Recurrent otorrhoea
bull Disabling conductive hearing loss bull Bilateral ( gt30 - 40 dB)
bull Unilateral
bull To allow watersports
Wullstein Classification of Tympanoplasty (1956)
bull Type I ndash Myringoplasty = 3 ossicles present amp drum repair
bull Type II ndash Malleusincus eroded ndash reconstruction preserves middle ear depth
bull Type III ndash Lateral ossicles gone graft onto stapes superstructure columella effect shallow ME cleft
bull Type IV ndash No ossicles graft onto footplate
bull Type V ndash graft onto fixed footplate Va = fenestration of LSSC
Tympoanoplasty Type 1 in children ndash an evaluative study
bull Gautam Bir Sing et al Int J Ped Otorninolaryngol 200569 (8)1071-76
bull 80 graft success rate at 6 month
bull 61 significant improved hearing
Meta-analysis of Pediatric Tympanoplasty
bull Vrabec et al Arch Otolaryngol H amp Neck Surg 1999 125 (5) 530-34
bull Graft take rate 80 in perf less than half TM
69 if over half TM
bull Take rate with good vs poor ET function 87 cf 77
bull Adenoids ndash no difference
bull Normal contralat ear vs abnormal 80 cf 71
bull Wet ear ndash no difference
bull Increased success rate with increasing Age (p =0005)
What Age to perform myringoplasty
bull Success rate not influenced by age (eg House Ear Institute
Chandrasekhar et al Arch Oto HampN Surg 1995 121873-878 and Denoyelle Garabedien group Paris Laryngoscope)
bull Mean age of most paediatric published series = 10 ndash 11 years (range 4 ndash 17)
bull General Advice (GMorrison) ndash Other ear predicts outcome ndash 7 ndash 8 yrs or over if infections controllable and one good
hearing ear ndash As early as 3 ndash 4 if bilat Subtotal perfs with disabling
hearing loss amp infections
Myringoplasty ndash Personal Surgical tips
bull Consider periosteum graft
bull Dry graft thoroughly
bull Trim graft to exact size (little finger nail)
bull Underlay or reverse thru-lay technique
bull ldquoKerrrdquo ant wall pocket if no anterior lip
bull Subcuticular resorbable sutures
bull BIPP pack(s) except v young
EAM
ME
Anterior
Cartilage Tympanoplasty
bull Jansen 1958
bull Heerman 1962 ndash cartilage palisade
bull Techniques
ndash Island graft
ndash Palisades
ndash Butterfly inlay
ndash Cartilage Shield
Indications for Cartilage Tympanoplasty
bull Retraction pockets
bull Atelectasis
bull Poor ET Function
bull To prevent prosthesis extrusion
bull (Revision Surgery)
Reinforcement Tympanoplasty for retraction
Post Cartilage Tympanoplasty amp Incus transposition
Surgical Outcomes for Paediatric Myringoplasty
bull Fat plug Myringoplasty ndash 80 success bull Paper - steristrip myringoplasty ndash 65 bull Formal Myringoplasty - over 80 closure - 60 - 81 hearing
success bull Hearing gain - ABG to lt 10 dB to 23 lt20 dB in 883
Risk of OME after repair ndash 78 Long term graft breakdown ndash 65
Wet Ear Surgery
bull Moist ear ndash OK
bull Purulent Ear ndash Surgery Contraindicated
Conclusions
bull AOM and CSOM without cholesteatoma can lead to intracranial complications
bull Persistent perforations post grommets are seen in up to 46 patients
bull Operate when ET function improved
bull Cartilage Tympanoplasty has advantages in special cases
bull You can routinely repair ears at 8 years
bull Surgery best avoided in a purulent ear
Thank You
How do you know if this retraction is going to progress
Grommets for Pars tensa retraction Pockets if under 10 and
bull Stage 1 and hearing loss from OME
bull Stage 2 and hearing loss or GENUINE erosion of LPI noted
bull Stage 3 with HL
bull Atelectasis Stage 4
Strategy for Pars Tensa Retractions
bull Use otoendoscope if limit not seen
bull Younger child ndash Repeated Ventilation tubes of hearing loss
bull Older child ndash consider excision amp grafting
bull Always montior the ME pressure -ve = delay surgery
bull Progressive or unstable poster-superior retraction - Operate
bull If hearing loss ndash offer surgery
bull Decision also depends on status of contralat ear age of patient amp historic
rate of progression
Reconstructive surgery for P tensa retraction if
bull Grade III retraction when adolescent
bull Retraction limits not seen in facial recess sinus tympani and unstable ndash periodic infections
bull Retraction into facial recess sinus tympani amp tympanogram improving
bull Grade IV retraction when adolescent
Mild retractionGood hearing
Pars tensa retraction pocket Atelectasiscollapse
Deep retractionEarly LPI erosion
Good or bad hearing
grommets
Glue earHearing loss
Trial grommets
Unstable retractionLimit of pocket out of view
Ossicular erosion
Reinforcement tympanoplasty+- ossiculoplasty
+- long term ventilation tube
Observation extrudes
Resolved discharge patient
lt10 years gt10 years
Failure
Summary
bull Classifications described
bull Vent Tubes correct Ptensa retractn while in situ
bull Postero-superior pockets can erode ossicles amp develop cholesteatoma
bull Surgery can be preventative or corrective
bull Operate if poor hearing or progression over time
bull Balance risks of surgery vs risks of non-intervention
bull Cartilage repair has gained popularity
Perforations
Safe vs Unsafe ears
bull Brain abscess
After cholesteatoma in 46
After mucosal disease in 38
After mod Rad mastoidectomy in 15
Browning GG The Unsafeness of safe ears JLO 1984a 9823-26
Aetiologies of TM Perforations
bull AOM perforation bull Otitis Externa ndash myringitis (fungal) bull CSOM bull Specific Chronic Suppurative Otitis Media TB Actinomyces Syphilis
bull Direct trauma to membrane bull Post ventilation tubes (275 ear 46 child 13 t-tubes)
bull Barotraumatic bull Blast Injury beware implantation
cholesteatoma
Size Matters
bull Conductive Hearing Loss variable 0 ndash 50 dB
bull Larger perforation = larger ABG
bull Low frequencies greatest affected
bull Post frac12 TM ndash transmits low frequency
bull Ant frac12 TM transmits high frequency
Management of TM perforations
bull Conservative ldquoA small perforation is good it acts as a natural ventilation
tuberdquo
Small hole no infections good hearing poor ETD = leave alone
bull Surgical ldquoThe perforation is bad it leads to recurrent ear infections
and restricts water sportsrdquo
Recurrent infections hearing loss other ear good = repair
Management of TM perforations
bull Conservative
bull Swabs + microsuction
bull Keep ear dry (earplugs for swimming)
bull Topical Agents - Ofloxacin or Ciprofloxacin drops + steroids
bull Systemic antibiotics
Management of TM perforations
bull Surgical
ndash Myringoplasty Tympanoplasty
ndash + - Adenoidectomy
Indications for repair of perforation
bull Any Ear with cholesteatoma
bull Not healed spontaneously after 6 months observation
andhellip
bull Recurrent otorrhoea
bull Disabling conductive hearing loss bull Bilateral ( gt30 - 40 dB)
bull Unilateral
bull To allow watersports
Wullstein Classification of Tympanoplasty (1956)
bull Type I ndash Myringoplasty = 3 ossicles present amp drum repair
bull Type II ndash Malleusincus eroded ndash reconstruction preserves middle ear depth
bull Type III ndash Lateral ossicles gone graft onto stapes superstructure columella effect shallow ME cleft
bull Type IV ndash No ossicles graft onto footplate
bull Type V ndash graft onto fixed footplate Va = fenestration of LSSC
Tympoanoplasty Type 1 in children ndash an evaluative study
bull Gautam Bir Sing et al Int J Ped Otorninolaryngol 200569 (8)1071-76
bull 80 graft success rate at 6 month
bull 61 significant improved hearing
Meta-analysis of Pediatric Tympanoplasty
bull Vrabec et al Arch Otolaryngol H amp Neck Surg 1999 125 (5) 530-34
bull Graft take rate 80 in perf less than half TM
69 if over half TM
bull Take rate with good vs poor ET function 87 cf 77
bull Adenoids ndash no difference
bull Normal contralat ear vs abnormal 80 cf 71
bull Wet ear ndash no difference
bull Increased success rate with increasing Age (p =0005)
What Age to perform myringoplasty
bull Success rate not influenced by age (eg House Ear Institute
Chandrasekhar et al Arch Oto HampN Surg 1995 121873-878 and Denoyelle Garabedien group Paris Laryngoscope)
bull Mean age of most paediatric published series = 10 ndash 11 years (range 4 ndash 17)
bull General Advice (GMorrison) ndash Other ear predicts outcome ndash 7 ndash 8 yrs or over if infections controllable and one good
hearing ear ndash As early as 3 ndash 4 if bilat Subtotal perfs with disabling
hearing loss amp infections
Myringoplasty ndash Personal Surgical tips
bull Consider periosteum graft
bull Dry graft thoroughly
bull Trim graft to exact size (little finger nail)
bull Underlay or reverse thru-lay technique
bull ldquoKerrrdquo ant wall pocket if no anterior lip
bull Subcuticular resorbable sutures
bull BIPP pack(s) except v young
EAM
ME
Anterior
Cartilage Tympanoplasty
bull Jansen 1958
bull Heerman 1962 ndash cartilage palisade
bull Techniques
ndash Island graft
ndash Palisades
ndash Butterfly inlay
ndash Cartilage Shield
Indications for Cartilage Tympanoplasty
bull Retraction pockets
bull Atelectasis
bull Poor ET Function
bull To prevent prosthesis extrusion
bull (Revision Surgery)
Reinforcement Tympanoplasty for retraction
Post Cartilage Tympanoplasty amp Incus transposition
Surgical Outcomes for Paediatric Myringoplasty
bull Fat plug Myringoplasty ndash 80 success bull Paper - steristrip myringoplasty ndash 65 bull Formal Myringoplasty - over 80 closure - 60 - 81 hearing
success bull Hearing gain - ABG to lt 10 dB to 23 lt20 dB in 883
Risk of OME after repair ndash 78 Long term graft breakdown ndash 65
Wet Ear Surgery
bull Moist ear ndash OK
bull Purulent Ear ndash Surgery Contraindicated
Conclusions
bull AOM and CSOM without cholesteatoma can lead to intracranial complications
bull Persistent perforations post grommets are seen in up to 46 patients
bull Operate when ET function improved
bull Cartilage Tympanoplasty has advantages in special cases
bull You can routinely repair ears at 8 years
bull Surgery best avoided in a purulent ear
Thank You
Grommets for Pars tensa retraction Pockets if under 10 and
bull Stage 1 and hearing loss from OME
bull Stage 2 and hearing loss or GENUINE erosion of LPI noted
bull Stage 3 with HL
bull Atelectasis Stage 4
Strategy for Pars Tensa Retractions
bull Use otoendoscope if limit not seen
bull Younger child ndash Repeated Ventilation tubes of hearing loss
bull Older child ndash consider excision amp grafting
bull Always montior the ME pressure -ve = delay surgery
bull Progressive or unstable poster-superior retraction - Operate
bull If hearing loss ndash offer surgery
bull Decision also depends on status of contralat ear age of patient amp historic
rate of progression
Reconstructive surgery for P tensa retraction if
bull Grade III retraction when adolescent
bull Retraction limits not seen in facial recess sinus tympani and unstable ndash periodic infections
bull Retraction into facial recess sinus tympani amp tympanogram improving
bull Grade IV retraction when adolescent
Mild retractionGood hearing
Pars tensa retraction pocket Atelectasiscollapse
Deep retractionEarly LPI erosion
Good or bad hearing
grommets
Glue earHearing loss
Trial grommets
Unstable retractionLimit of pocket out of view
Ossicular erosion
Reinforcement tympanoplasty+- ossiculoplasty
+- long term ventilation tube
Observation extrudes
Resolved discharge patient
lt10 years gt10 years
Failure
Summary
bull Classifications described
bull Vent Tubes correct Ptensa retractn while in situ
bull Postero-superior pockets can erode ossicles amp develop cholesteatoma
bull Surgery can be preventative or corrective
bull Operate if poor hearing or progression over time
bull Balance risks of surgery vs risks of non-intervention
bull Cartilage repair has gained popularity
Perforations
Safe vs Unsafe ears
bull Brain abscess
After cholesteatoma in 46
After mucosal disease in 38
After mod Rad mastoidectomy in 15
Browning GG The Unsafeness of safe ears JLO 1984a 9823-26
Aetiologies of TM Perforations
bull AOM perforation bull Otitis Externa ndash myringitis (fungal) bull CSOM bull Specific Chronic Suppurative Otitis Media TB Actinomyces Syphilis
bull Direct trauma to membrane bull Post ventilation tubes (275 ear 46 child 13 t-tubes)
bull Barotraumatic bull Blast Injury beware implantation
cholesteatoma
Size Matters
bull Conductive Hearing Loss variable 0 ndash 50 dB
bull Larger perforation = larger ABG
bull Low frequencies greatest affected
bull Post frac12 TM ndash transmits low frequency
bull Ant frac12 TM transmits high frequency
Management of TM perforations
bull Conservative ldquoA small perforation is good it acts as a natural ventilation
tuberdquo
Small hole no infections good hearing poor ETD = leave alone
bull Surgical ldquoThe perforation is bad it leads to recurrent ear infections
and restricts water sportsrdquo
Recurrent infections hearing loss other ear good = repair
Management of TM perforations
bull Conservative
bull Swabs + microsuction
bull Keep ear dry (earplugs for swimming)
bull Topical Agents - Ofloxacin or Ciprofloxacin drops + steroids
bull Systemic antibiotics
Management of TM perforations
bull Surgical
ndash Myringoplasty Tympanoplasty
ndash + - Adenoidectomy
Indications for repair of perforation
bull Any Ear with cholesteatoma
bull Not healed spontaneously after 6 months observation
andhellip
bull Recurrent otorrhoea
bull Disabling conductive hearing loss bull Bilateral ( gt30 - 40 dB)
bull Unilateral
bull To allow watersports
Wullstein Classification of Tympanoplasty (1956)
bull Type I ndash Myringoplasty = 3 ossicles present amp drum repair
bull Type II ndash Malleusincus eroded ndash reconstruction preserves middle ear depth
bull Type III ndash Lateral ossicles gone graft onto stapes superstructure columella effect shallow ME cleft
bull Type IV ndash No ossicles graft onto footplate
bull Type V ndash graft onto fixed footplate Va = fenestration of LSSC
Tympoanoplasty Type 1 in children ndash an evaluative study
bull Gautam Bir Sing et al Int J Ped Otorninolaryngol 200569 (8)1071-76
bull 80 graft success rate at 6 month
bull 61 significant improved hearing
Meta-analysis of Pediatric Tympanoplasty
bull Vrabec et al Arch Otolaryngol H amp Neck Surg 1999 125 (5) 530-34
bull Graft take rate 80 in perf less than half TM
69 if over half TM
bull Take rate with good vs poor ET function 87 cf 77
bull Adenoids ndash no difference
bull Normal contralat ear vs abnormal 80 cf 71
bull Wet ear ndash no difference
bull Increased success rate with increasing Age (p =0005)
What Age to perform myringoplasty
bull Success rate not influenced by age (eg House Ear Institute
Chandrasekhar et al Arch Oto HampN Surg 1995 121873-878 and Denoyelle Garabedien group Paris Laryngoscope)
bull Mean age of most paediatric published series = 10 ndash 11 years (range 4 ndash 17)
bull General Advice (GMorrison) ndash Other ear predicts outcome ndash 7 ndash 8 yrs or over if infections controllable and one good
hearing ear ndash As early as 3 ndash 4 if bilat Subtotal perfs with disabling
hearing loss amp infections
Myringoplasty ndash Personal Surgical tips
bull Consider periosteum graft
bull Dry graft thoroughly
bull Trim graft to exact size (little finger nail)
bull Underlay or reverse thru-lay technique
bull ldquoKerrrdquo ant wall pocket if no anterior lip
bull Subcuticular resorbable sutures
bull BIPP pack(s) except v young
EAM
ME
Anterior
Cartilage Tympanoplasty
bull Jansen 1958
bull Heerman 1962 ndash cartilage palisade
bull Techniques
ndash Island graft
ndash Palisades
ndash Butterfly inlay
ndash Cartilage Shield
Indications for Cartilage Tympanoplasty
bull Retraction pockets
bull Atelectasis
bull Poor ET Function
bull To prevent prosthesis extrusion
bull (Revision Surgery)
Reinforcement Tympanoplasty for retraction
Post Cartilage Tympanoplasty amp Incus transposition
Surgical Outcomes for Paediatric Myringoplasty
bull Fat plug Myringoplasty ndash 80 success bull Paper - steristrip myringoplasty ndash 65 bull Formal Myringoplasty - over 80 closure - 60 - 81 hearing
success bull Hearing gain - ABG to lt 10 dB to 23 lt20 dB in 883
Risk of OME after repair ndash 78 Long term graft breakdown ndash 65
Wet Ear Surgery
bull Moist ear ndash OK
bull Purulent Ear ndash Surgery Contraindicated
Conclusions
bull AOM and CSOM without cholesteatoma can lead to intracranial complications
bull Persistent perforations post grommets are seen in up to 46 patients
bull Operate when ET function improved
bull Cartilage Tympanoplasty has advantages in special cases
bull You can routinely repair ears at 8 years
bull Surgery best avoided in a purulent ear
Thank You
Strategy for Pars Tensa Retractions
bull Use otoendoscope if limit not seen
bull Younger child ndash Repeated Ventilation tubes of hearing loss
bull Older child ndash consider excision amp grafting
bull Always montior the ME pressure -ve = delay surgery
bull Progressive or unstable poster-superior retraction - Operate
bull If hearing loss ndash offer surgery
bull Decision also depends on status of contralat ear age of patient amp historic
rate of progression
Reconstructive surgery for P tensa retraction if
bull Grade III retraction when adolescent
bull Retraction limits not seen in facial recess sinus tympani and unstable ndash periodic infections
bull Retraction into facial recess sinus tympani amp tympanogram improving
bull Grade IV retraction when adolescent
Mild retractionGood hearing
Pars tensa retraction pocket Atelectasiscollapse
Deep retractionEarly LPI erosion
Good or bad hearing
grommets
Glue earHearing loss
Trial grommets
Unstable retractionLimit of pocket out of view
Ossicular erosion
Reinforcement tympanoplasty+- ossiculoplasty
+- long term ventilation tube
Observation extrudes
Resolved discharge patient
lt10 years gt10 years
Failure
Summary
bull Classifications described
bull Vent Tubes correct Ptensa retractn while in situ
bull Postero-superior pockets can erode ossicles amp develop cholesteatoma
bull Surgery can be preventative or corrective
bull Operate if poor hearing or progression over time
bull Balance risks of surgery vs risks of non-intervention
bull Cartilage repair has gained popularity
Perforations
Safe vs Unsafe ears
bull Brain abscess
After cholesteatoma in 46
After mucosal disease in 38
After mod Rad mastoidectomy in 15
Browning GG The Unsafeness of safe ears JLO 1984a 9823-26
Aetiologies of TM Perforations
bull AOM perforation bull Otitis Externa ndash myringitis (fungal) bull CSOM bull Specific Chronic Suppurative Otitis Media TB Actinomyces Syphilis
bull Direct trauma to membrane bull Post ventilation tubes (275 ear 46 child 13 t-tubes)
bull Barotraumatic bull Blast Injury beware implantation
cholesteatoma
Size Matters
bull Conductive Hearing Loss variable 0 ndash 50 dB
bull Larger perforation = larger ABG
bull Low frequencies greatest affected
bull Post frac12 TM ndash transmits low frequency
bull Ant frac12 TM transmits high frequency
Management of TM perforations
bull Conservative ldquoA small perforation is good it acts as a natural ventilation
tuberdquo
Small hole no infections good hearing poor ETD = leave alone
bull Surgical ldquoThe perforation is bad it leads to recurrent ear infections
and restricts water sportsrdquo
Recurrent infections hearing loss other ear good = repair
Management of TM perforations
bull Conservative
bull Swabs + microsuction
bull Keep ear dry (earplugs for swimming)
bull Topical Agents - Ofloxacin or Ciprofloxacin drops + steroids
bull Systemic antibiotics
Management of TM perforations
bull Surgical
ndash Myringoplasty Tympanoplasty
ndash + - Adenoidectomy
Indications for repair of perforation
bull Any Ear with cholesteatoma
bull Not healed spontaneously after 6 months observation
andhellip
bull Recurrent otorrhoea
bull Disabling conductive hearing loss bull Bilateral ( gt30 - 40 dB)
bull Unilateral
bull To allow watersports
Wullstein Classification of Tympanoplasty (1956)
bull Type I ndash Myringoplasty = 3 ossicles present amp drum repair
bull Type II ndash Malleusincus eroded ndash reconstruction preserves middle ear depth
bull Type III ndash Lateral ossicles gone graft onto stapes superstructure columella effect shallow ME cleft
bull Type IV ndash No ossicles graft onto footplate
bull Type V ndash graft onto fixed footplate Va = fenestration of LSSC
Tympoanoplasty Type 1 in children ndash an evaluative study
bull Gautam Bir Sing et al Int J Ped Otorninolaryngol 200569 (8)1071-76
bull 80 graft success rate at 6 month
bull 61 significant improved hearing
Meta-analysis of Pediatric Tympanoplasty
bull Vrabec et al Arch Otolaryngol H amp Neck Surg 1999 125 (5) 530-34
bull Graft take rate 80 in perf less than half TM
69 if over half TM
bull Take rate with good vs poor ET function 87 cf 77
bull Adenoids ndash no difference
bull Normal contralat ear vs abnormal 80 cf 71
bull Wet ear ndash no difference
bull Increased success rate with increasing Age (p =0005)
What Age to perform myringoplasty
bull Success rate not influenced by age (eg House Ear Institute
Chandrasekhar et al Arch Oto HampN Surg 1995 121873-878 and Denoyelle Garabedien group Paris Laryngoscope)
bull Mean age of most paediatric published series = 10 ndash 11 years (range 4 ndash 17)
bull General Advice (GMorrison) ndash Other ear predicts outcome ndash 7 ndash 8 yrs or over if infections controllable and one good
hearing ear ndash As early as 3 ndash 4 if bilat Subtotal perfs with disabling
hearing loss amp infections
Myringoplasty ndash Personal Surgical tips
bull Consider periosteum graft
bull Dry graft thoroughly
bull Trim graft to exact size (little finger nail)
bull Underlay or reverse thru-lay technique
bull ldquoKerrrdquo ant wall pocket if no anterior lip
bull Subcuticular resorbable sutures
bull BIPP pack(s) except v young
EAM
ME
Anterior
Cartilage Tympanoplasty
bull Jansen 1958
bull Heerman 1962 ndash cartilage palisade
bull Techniques
ndash Island graft
ndash Palisades
ndash Butterfly inlay
ndash Cartilage Shield
Indications for Cartilage Tympanoplasty
bull Retraction pockets
bull Atelectasis
bull Poor ET Function
bull To prevent prosthesis extrusion
bull (Revision Surgery)
Reinforcement Tympanoplasty for retraction
Post Cartilage Tympanoplasty amp Incus transposition
Surgical Outcomes for Paediatric Myringoplasty
bull Fat plug Myringoplasty ndash 80 success bull Paper - steristrip myringoplasty ndash 65 bull Formal Myringoplasty - over 80 closure - 60 - 81 hearing
success bull Hearing gain - ABG to lt 10 dB to 23 lt20 dB in 883
Risk of OME after repair ndash 78 Long term graft breakdown ndash 65
Wet Ear Surgery
bull Moist ear ndash OK
bull Purulent Ear ndash Surgery Contraindicated
Conclusions
bull AOM and CSOM without cholesteatoma can lead to intracranial complications
bull Persistent perforations post grommets are seen in up to 46 patients
bull Operate when ET function improved
bull Cartilage Tympanoplasty has advantages in special cases
bull You can routinely repair ears at 8 years
bull Surgery best avoided in a purulent ear
Thank You
Reconstructive surgery for P tensa retraction if
bull Grade III retraction when adolescent
bull Retraction limits not seen in facial recess sinus tympani and unstable ndash periodic infections
bull Retraction into facial recess sinus tympani amp tympanogram improving
bull Grade IV retraction when adolescent
Mild retractionGood hearing
Pars tensa retraction pocket Atelectasiscollapse
Deep retractionEarly LPI erosion
Good or bad hearing
grommets
Glue earHearing loss
Trial grommets
Unstable retractionLimit of pocket out of view
Ossicular erosion
Reinforcement tympanoplasty+- ossiculoplasty
+- long term ventilation tube
Observation extrudes
Resolved discharge patient
lt10 years gt10 years
Failure
Summary
bull Classifications described
bull Vent Tubes correct Ptensa retractn while in situ
bull Postero-superior pockets can erode ossicles amp develop cholesteatoma
bull Surgery can be preventative or corrective
bull Operate if poor hearing or progression over time
bull Balance risks of surgery vs risks of non-intervention
bull Cartilage repair has gained popularity
Perforations
Safe vs Unsafe ears
bull Brain abscess
After cholesteatoma in 46
After mucosal disease in 38
After mod Rad mastoidectomy in 15
Browning GG The Unsafeness of safe ears JLO 1984a 9823-26
Aetiologies of TM Perforations
bull AOM perforation bull Otitis Externa ndash myringitis (fungal) bull CSOM bull Specific Chronic Suppurative Otitis Media TB Actinomyces Syphilis
bull Direct trauma to membrane bull Post ventilation tubes (275 ear 46 child 13 t-tubes)
bull Barotraumatic bull Blast Injury beware implantation
cholesteatoma
Size Matters
bull Conductive Hearing Loss variable 0 ndash 50 dB
bull Larger perforation = larger ABG
bull Low frequencies greatest affected
bull Post frac12 TM ndash transmits low frequency
bull Ant frac12 TM transmits high frequency
Management of TM perforations
bull Conservative ldquoA small perforation is good it acts as a natural ventilation
tuberdquo
Small hole no infections good hearing poor ETD = leave alone
bull Surgical ldquoThe perforation is bad it leads to recurrent ear infections
and restricts water sportsrdquo
Recurrent infections hearing loss other ear good = repair
Management of TM perforations
bull Conservative
bull Swabs + microsuction
bull Keep ear dry (earplugs for swimming)
bull Topical Agents - Ofloxacin or Ciprofloxacin drops + steroids
bull Systemic antibiotics
Management of TM perforations
bull Surgical
ndash Myringoplasty Tympanoplasty
ndash + - Adenoidectomy
Indications for repair of perforation
bull Any Ear with cholesteatoma
bull Not healed spontaneously after 6 months observation
andhellip
bull Recurrent otorrhoea
bull Disabling conductive hearing loss bull Bilateral ( gt30 - 40 dB)
bull Unilateral
bull To allow watersports
Wullstein Classification of Tympanoplasty (1956)
bull Type I ndash Myringoplasty = 3 ossicles present amp drum repair
bull Type II ndash Malleusincus eroded ndash reconstruction preserves middle ear depth
bull Type III ndash Lateral ossicles gone graft onto stapes superstructure columella effect shallow ME cleft
bull Type IV ndash No ossicles graft onto footplate
bull Type V ndash graft onto fixed footplate Va = fenestration of LSSC
Tympoanoplasty Type 1 in children ndash an evaluative study
bull Gautam Bir Sing et al Int J Ped Otorninolaryngol 200569 (8)1071-76
bull 80 graft success rate at 6 month
bull 61 significant improved hearing
Meta-analysis of Pediatric Tympanoplasty
bull Vrabec et al Arch Otolaryngol H amp Neck Surg 1999 125 (5) 530-34
bull Graft take rate 80 in perf less than half TM
69 if over half TM
bull Take rate with good vs poor ET function 87 cf 77
bull Adenoids ndash no difference
bull Normal contralat ear vs abnormal 80 cf 71
bull Wet ear ndash no difference
bull Increased success rate with increasing Age (p =0005)
What Age to perform myringoplasty
bull Success rate not influenced by age (eg House Ear Institute
Chandrasekhar et al Arch Oto HampN Surg 1995 121873-878 and Denoyelle Garabedien group Paris Laryngoscope)
bull Mean age of most paediatric published series = 10 ndash 11 years (range 4 ndash 17)
bull General Advice (GMorrison) ndash Other ear predicts outcome ndash 7 ndash 8 yrs or over if infections controllable and one good
hearing ear ndash As early as 3 ndash 4 if bilat Subtotal perfs with disabling
hearing loss amp infections
Myringoplasty ndash Personal Surgical tips
bull Consider periosteum graft
bull Dry graft thoroughly
bull Trim graft to exact size (little finger nail)
bull Underlay or reverse thru-lay technique
bull ldquoKerrrdquo ant wall pocket if no anterior lip
bull Subcuticular resorbable sutures
bull BIPP pack(s) except v young
EAM
ME
Anterior
Cartilage Tympanoplasty
bull Jansen 1958
bull Heerman 1962 ndash cartilage palisade
bull Techniques
ndash Island graft
ndash Palisades
ndash Butterfly inlay
ndash Cartilage Shield
Indications for Cartilage Tympanoplasty
bull Retraction pockets
bull Atelectasis
bull Poor ET Function
bull To prevent prosthesis extrusion
bull (Revision Surgery)
Reinforcement Tympanoplasty for retraction
Post Cartilage Tympanoplasty amp Incus transposition
Surgical Outcomes for Paediatric Myringoplasty
bull Fat plug Myringoplasty ndash 80 success bull Paper - steristrip myringoplasty ndash 65 bull Formal Myringoplasty - over 80 closure - 60 - 81 hearing
success bull Hearing gain - ABG to lt 10 dB to 23 lt20 dB in 883
Risk of OME after repair ndash 78 Long term graft breakdown ndash 65
Wet Ear Surgery
bull Moist ear ndash OK
bull Purulent Ear ndash Surgery Contraindicated
Conclusions
bull AOM and CSOM without cholesteatoma can lead to intracranial complications
bull Persistent perforations post grommets are seen in up to 46 patients
bull Operate when ET function improved
bull Cartilage Tympanoplasty has advantages in special cases
bull You can routinely repair ears at 8 years
bull Surgery best avoided in a purulent ear
Thank You
Mild retractionGood hearing
Pars tensa retraction pocket Atelectasiscollapse
Deep retractionEarly LPI erosion
Good or bad hearing
grommets
Glue earHearing loss
Trial grommets
Unstable retractionLimit of pocket out of view
Ossicular erosion
Reinforcement tympanoplasty+- ossiculoplasty
+- long term ventilation tube
Observation extrudes
Resolved discharge patient
lt10 years gt10 years
Failure
Summary
bull Classifications described
bull Vent Tubes correct Ptensa retractn while in situ
bull Postero-superior pockets can erode ossicles amp develop cholesteatoma
bull Surgery can be preventative or corrective
bull Operate if poor hearing or progression over time
bull Balance risks of surgery vs risks of non-intervention
bull Cartilage repair has gained popularity
Perforations
Safe vs Unsafe ears
bull Brain abscess
After cholesteatoma in 46
After mucosal disease in 38
After mod Rad mastoidectomy in 15
Browning GG The Unsafeness of safe ears JLO 1984a 9823-26
Aetiologies of TM Perforations
bull AOM perforation bull Otitis Externa ndash myringitis (fungal) bull CSOM bull Specific Chronic Suppurative Otitis Media TB Actinomyces Syphilis
bull Direct trauma to membrane bull Post ventilation tubes (275 ear 46 child 13 t-tubes)
bull Barotraumatic bull Blast Injury beware implantation
cholesteatoma
Size Matters
bull Conductive Hearing Loss variable 0 ndash 50 dB
bull Larger perforation = larger ABG
bull Low frequencies greatest affected
bull Post frac12 TM ndash transmits low frequency
bull Ant frac12 TM transmits high frequency
Management of TM perforations
bull Conservative ldquoA small perforation is good it acts as a natural ventilation
tuberdquo
Small hole no infections good hearing poor ETD = leave alone
bull Surgical ldquoThe perforation is bad it leads to recurrent ear infections
and restricts water sportsrdquo
Recurrent infections hearing loss other ear good = repair
Management of TM perforations
bull Conservative
bull Swabs + microsuction
bull Keep ear dry (earplugs for swimming)
bull Topical Agents - Ofloxacin or Ciprofloxacin drops + steroids
bull Systemic antibiotics
Management of TM perforations
bull Surgical
ndash Myringoplasty Tympanoplasty
ndash + - Adenoidectomy
Indications for repair of perforation
bull Any Ear with cholesteatoma
bull Not healed spontaneously after 6 months observation
andhellip
bull Recurrent otorrhoea
bull Disabling conductive hearing loss bull Bilateral ( gt30 - 40 dB)
bull Unilateral
bull To allow watersports
Wullstein Classification of Tympanoplasty (1956)
bull Type I ndash Myringoplasty = 3 ossicles present amp drum repair
bull Type II ndash Malleusincus eroded ndash reconstruction preserves middle ear depth
bull Type III ndash Lateral ossicles gone graft onto stapes superstructure columella effect shallow ME cleft
bull Type IV ndash No ossicles graft onto footplate
bull Type V ndash graft onto fixed footplate Va = fenestration of LSSC
Tympoanoplasty Type 1 in children ndash an evaluative study
bull Gautam Bir Sing et al Int J Ped Otorninolaryngol 200569 (8)1071-76
bull 80 graft success rate at 6 month
bull 61 significant improved hearing
Meta-analysis of Pediatric Tympanoplasty
bull Vrabec et al Arch Otolaryngol H amp Neck Surg 1999 125 (5) 530-34
bull Graft take rate 80 in perf less than half TM
69 if over half TM
bull Take rate with good vs poor ET function 87 cf 77
bull Adenoids ndash no difference
bull Normal contralat ear vs abnormal 80 cf 71
bull Wet ear ndash no difference
bull Increased success rate with increasing Age (p =0005)
What Age to perform myringoplasty
bull Success rate not influenced by age (eg House Ear Institute
Chandrasekhar et al Arch Oto HampN Surg 1995 121873-878 and Denoyelle Garabedien group Paris Laryngoscope)
bull Mean age of most paediatric published series = 10 ndash 11 years (range 4 ndash 17)
bull General Advice (GMorrison) ndash Other ear predicts outcome ndash 7 ndash 8 yrs or over if infections controllable and one good
hearing ear ndash As early as 3 ndash 4 if bilat Subtotal perfs with disabling
hearing loss amp infections
Myringoplasty ndash Personal Surgical tips
bull Consider periosteum graft
bull Dry graft thoroughly
bull Trim graft to exact size (little finger nail)
bull Underlay or reverse thru-lay technique
bull ldquoKerrrdquo ant wall pocket if no anterior lip
bull Subcuticular resorbable sutures
bull BIPP pack(s) except v young
EAM
ME
Anterior
Cartilage Tympanoplasty
bull Jansen 1958
bull Heerman 1962 ndash cartilage palisade
bull Techniques
ndash Island graft
ndash Palisades
ndash Butterfly inlay
ndash Cartilage Shield
Indications for Cartilage Tympanoplasty
bull Retraction pockets
bull Atelectasis
bull Poor ET Function
bull To prevent prosthesis extrusion
bull (Revision Surgery)
Reinforcement Tympanoplasty for retraction
Post Cartilage Tympanoplasty amp Incus transposition
Surgical Outcomes for Paediatric Myringoplasty
bull Fat plug Myringoplasty ndash 80 success bull Paper - steristrip myringoplasty ndash 65 bull Formal Myringoplasty - over 80 closure - 60 - 81 hearing
success bull Hearing gain - ABG to lt 10 dB to 23 lt20 dB in 883
Risk of OME after repair ndash 78 Long term graft breakdown ndash 65
Wet Ear Surgery
bull Moist ear ndash OK
bull Purulent Ear ndash Surgery Contraindicated
Conclusions
bull AOM and CSOM without cholesteatoma can lead to intracranial complications
bull Persistent perforations post grommets are seen in up to 46 patients
bull Operate when ET function improved
bull Cartilage Tympanoplasty has advantages in special cases
bull You can routinely repair ears at 8 years
bull Surgery best avoided in a purulent ear
Thank You
Summary
bull Classifications described
bull Vent Tubes correct Ptensa retractn while in situ
bull Postero-superior pockets can erode ossicles amp develop cholesteatoma
bull Surgery can be preventative or corrective
bull Operate if poor hearing or progression over time
bull Balance risks of surgery vs risks of non-intervention
bull Cartilage repair has gained popularity
Perforations
Safe vs Unsafe ears
bull Brain abscess
After cholesteatoma in 46
After mucosal disease in 38
After mod Rad mastoidectomy in 15
Browning GG The Unsafeness of safe ears JLO 1984a 9823-26
Aetiologies of TM Perforations
bull AOM perforation bull Otitis Externa ndash myringitis (fungal) bull CSOM bull Specific Chronic Suppurative Otitis Media TB Actinomyces Syphilis
bull Direct trauma to membrane bull Post ventilation tubes (275 ear 46 child 13 t-tubes)
bull Barotraumatic bull Blast Injury beware implantation
cholesteatoma
Size Matters
bull Conductive Hearing Loss variable 0 ndash 50 dB
bull Larger perforation = larger ABG
bull Low frequencies greatest affected
bull Post frac12 TM ndash transmits low frequency
bull Ant frac12 TM transmits high frequency
Management of TM perforations
bull Conservative ldquoA small perforation is good it acts as a natural ventilation
tuberdquo
Small hole no infections good hearing poor ETD = leave alone
bull Surgical ldquoThe perforation is bad it leads to recurrent ear infections
and restricts water sportsrdquo
Recurrent infections hearing loss other ear good = repair
Management of TM perforations
bull Conservative
bull Swabs + microsuction
bull Keep ear dry (earplugs for swimming)
bull Topical Agents - Ofloxacin or Ciprofloxacin drops + steroids
bull Systemic antibiotics
Management of TM perforations
bull Surgical
ndash Myringoplasty Tympanoplasty
ndash + - Adenoidectomy
Indications for repair of perforation
bull Any Ear with cholesteatoma
bull Not healed spontaneously after 6 months observation
andhellip
bull Recurrent otorrhoea
bull Disabling conductive hearing loss bull Bilateral ( gt30 - 40 dB)
bull Unilateral
bull To allow watersports
Wullstein Classification of Tympanoplasty (1956)
bull Type I ndash Myringoplasty = 3 ossicles present amp drum repair
bull Type II ndash Malleusincus eroded ndash reconstruction preserves middle ear depth
bull Type III ndash Lateral ossicles gone graft onto stapes superstructure columella effect shallow ME cleft
bull Type IV ndash No ossicles graft onto footplate
bull Type V ndash graft onto fixed footplate Va = fenestration of LSSC
Tympoanoplasty Type 1 in children ndash an evaluative study
bull Gautam Bir Sing et al Int J Ped Otorninolaryngol 200569 (8)1071-76
bull 80 graft success rate at 6 month
bull 61 significant improved hearing
Meta-analysis of Pediatric Tympanoplasty
bull Vrabec et al Arch Otolaryngol H amp Neck Surg 1999 125 (5) 530-34
bull Graft take rate 80 in perf less than half TM
69 if over half TM
bull Take rate with good vs poor ET function 87 cf 77
bull Adenoids ndash no difference
bull Normal contralat ear vs abnormal 80 cf 71
bull Wet ear ndash no difference
bull Increased success rate with increasing Age (p =0005)
What Age to perform myringoplasty
bull Success rate not influenced by age (eg House Ear Institute
Chandrasekhar et al Arch Oto HampN Surg 1995 121873-878 and Denoyelle Garabedien group Paris Laryngoscope)
bull Mean age of most paediatric published series = 10 ndash 11 years (range 4 ndash 17)
bull General Advice (GMorrison) ndash Other ear predicts outcome ndash 7 ndash 8 yrs or over if infections controllable and one good
hearing ear ndash As early as 3 ndash 4 if bilat Subtotal perfs with disabling
hearing loss amp infections
Myringoplasty ndash Personal Surgical tips
bull Consider periosteum graft
bull Dry graft thoroughly
bull Trim graft to exact size (little finger nail)
bull Underlay or reverse thru-lay technique
bull ldquoKerrrdquo ant wall pocket if no anterior lip
bull Subcuticular resorbable sutures
bull BIPP pack(s) except v young
EAM
ME
Anterior
Cartilage Tympanoplasty
bull Jansen 1958
bull Heerman 1962 ndash cartilage palisade
bull Techniques
ndash Island graft
ndash Palisades
ndash Butterfly inlay
ndash Cartilage Shield
Indications for Cartilage Tympanoplasty
bull Retraction pockets
bull Atelectasis
bull Poor ET Function
bull To prevent prosthesis extrusion
bull (Revision Surgery)
Reinforcement Tympanoplasty for retraction
Post Cartilage Tympanoplasty amp Incus transposition
Surgical Outcomes for Paediatric Myringoplasty
bull Fat plug Myringoplasty ndash 80 success bull Paper - steristrip myringoplasty ndash 65 bull Formal Myringoplasty - over 80 closure - 60 - 81 hearing
success bull Hearing gain - ABG to lt 10 dB to 23 lt20 dB in 883
Risk of OME after repair ndash 78 Long term graft breakdown ndash 65
Wet Ear Surgery
bull Moist ear ndash OK
bull Purulent Ear ndash Surgery Contraindicated
Conclusions
bull AOM and CSOM without cholesteatoma can lead to intracranial complications
bull Persistent perforations post grommets are seen in up to 46 patients
bull Operate when ET function improved
bull Cartilage Tympanoplasty has advantages in special cases
bull You can routinely repair ears at 8 years
bull Surgery best avoided in a purulent ear
Thank You
Perforations
Safe vs Unsafe ears
bull Brain abscess
After cholesteatoma in 46
After mucosal disease in 38
After mod Rad mastoidectomy in 15
Browning GG The Unsafeness of safe ears JLO 1984a 9823-26
Aetiologies of TM Perforations
bull AOM perforation bull Otitis Externa ndash myringitis (fungal) bull CSOM bull Specific Chronic Suppurative Otitis Media TB Actinomyces Syphilis
bull Direct trauma to membrane bull Post ventilation tubes (275 ear 46 child 13 t-tubes)
bull Barotraumatic bull Blast Injury beware implantation
cholesteatoma
Size Matters
bull Conductive Hearing Loss variable 0 ndash 50 dB
bull Larger perforation = larger ABG
bull Low frequencies greatest affected
bull Post frac12 TM ndash transmits low frequency
bull Ant frac12 TM transmits high frequency
Management of TM perforations
bull Conservative ldquoA small perforation is good it acts as a natural ventilation
tuberdquo
Small hole no infections good hearing poor ETD = leave alone
bull Surgical ldquoThe perforation is bad it leads to recurrent ear infections
and restricts water sportsrdquo
Recurrent infections hearing loss other ear good = repair
Management of TM perforations
bull Conservative
bull Swabs + microsuction
bull Keep ear dry (earplugs for swimming)
bull Topical Agents - Ofloxacin or Ciprofloxacin drops + steroids
bull Systemic antibiotics
Management of TM perforations
bull Surgical
ndash Myringoplasty Tympanoplasty
ndash + - Adenoidectomy
Indications for repair of perforation
bull Any Ear with cholesteatoma
bull Not healed spontaneously after 6 months observation
andhellip
bull Recurrent otorrhoea
bull Disabling conductive hearing loss bull Bilateral ( gt30 - 40 dB)
bull Unilateral
bull To allow watersports
Wullstein Classification of Tympanoplasty (1956)
bull Type I ndash Myringoplasty = 3 ossicles present amp drum repair
bull Type II ndash Malleusincus eroded ndash reconstruction preserves middle ear depth
bull Type III ndash Lateral ossicles gone graft onto stapes superstructure columella effect shallow ME cleft
bull Type IV ndash No ossicles graft onto footplate
bull Type V ndash graft onto fixed footplate Va = fenestration of LSSC
Tympoanoplasty Type 1 in children ndash an evaluative study
bull Gautam Bir Sing et al Int J Ped Otorninolaryngol 200569 (8)1071-76
bull 80 graft success rate at 6 month
bull 61 significant improved hearing
Meta-analysis of Pediatric Tympanoplasty
bull Vrabec et al Arch Otolaryngol H amp Neck Surg 1999 125 (5) 530-34
bull Graft take rate 80 in perf less than half TM
69 if over half TM
bull Take rate with good vs poor ET function 87 cf 77
bull Adenoids ndash no difference
bull Normal contralat ear vs abnormal 80 cf 71
bull Wet ear ndash no difference
bull Increased success rate with increasing Age (p =0005)
What Age to perform myringoplasty
bull Success rate not influenced by age (eg House Ear Institute
Chandrasekhar et al Arch Oto HampN Surg 1995 121873-878 and Denoyelle Garabedien group Paris Laryngoscope)
bull Mean age of most paediatric published series = 10 ndash 11 years (range 4 ndash 17)
bull General Advice (GMorrison) ndash Other ear predicts outcome ndash 7 ndash 8 yrs or over if infections controllable and one good
hearing ear ndash As early as 3 ndash 4 if bilat Subtotal perfs with disabling
hearing loss amp infections
Myringoplasty ndash Personal Surgical tips
bull Consider periosteum graft
bull Dry graft thoroughly
bull Trim graft to exact size (little finger nail)
bull Underlay or reverse thru-lay technique
bull ldquoKerrrdquo ant wall pocket if no anterior lip
bull Subcuticular resorbable sutures
bull BIPP pack(s) except v young
EAM
ME
Anterior
Cartilage Tympanoplasty
bull Jansen 1958
bull Heerman 1962 ndash cartilage palisade
bull Techniques
ndash Island graft
ndash Palisades
ndash Butterfly inlay
ndash Cartilage Shield
Indications for Cartilage Tympanoplasty
bull Retraction pockets
bull Atelectasis
bull Poor ET Function
bull To prevent prosthesis extrusion
bull (Revision Surgery)
Reinforcement Tympanoplasty for retraction
Post Cartilage Tympanoplasty amp Incus transposition
Surgical Outcomes for Paediatric Myringoplasty
bull Fat plug Myringoplasty ndash 80 success bull Paper - steristrip myringoplasty ndash 65 bull Formal Myringoplasty - over 80 closure - 60 - 81 hearing
success bull Hearing gain - ABG to lt 10 dB to 23 lt20 dB in 883
Risk of OME after repair ndash 78 Long term graft breakdown ndash 65
Wet Ear Surgery
bull Moist ear ndash OK
bull Purulent Ear ndash Surgery Contraindicated
Conclusions
bull AOM and CSOM without cholesteatoma can lead to intracranial complications
bull Persistent perforations post grommets are seen in up to 46 patients
bull Operate when ET function improved
bull Cartilage Tympanoplasty has advantages in special cases
bull You can routinely repair ears at 8 years
bull Surgery best avoided in a purulent ear
Thank You
Safe vs Unsafe ears
bull Brain abscess
After cholesteatoma in 46
After mucosal disease in 38
After mod Rad mastoidectomy in 15
Browning GG The Unsafeness of safe ears JLO 1984a 9823-26
Aetiologies of TM Perforations
bull AOM perforation bull Otitis Externa ndash myringitis (fungal) bull CSOM bull Specific Chronic Suppurative Otitis Media TB Actinomyces Syphilis
bull Direct trauma to membrane bull Post ventilation tubes (275 ear 46 child 13 t-tubes)
bull Barotraumatic bull Blast Injury beware implantation
cholesteatoma
Size Matters
bull Conductive Hearing Loss variable 0 ndash 50 dB
bull Larger perforation = larger ABG
bull Low frequencies greatest affected
bull Post frac12 TM ndash transmits low frequency
bull Ant frac12 TM transmits high frequency
Management of TM perforations
bull Conservative ldquoA small perforation is good it acts as a natural ventilation
tuberdquo
Small hole no infections good hearing poor ETD = leave alone
bull Surgical ldquoThe perforation is bad it leads to recurrent ear infections
and restricts water sportsrdquo
Recurrent infections hearing loss other ear good = repair
Management of TM perforations
bull Conservative
bull Swabs + microsuction
bull Keep ear dry (earplugs for swimming)
bull Topical Agents - Ofloxacin or Ciprofloxacin drops + steroids
bull Systemic antibiotics
Management of TM perforations
bull Surgical
ndash Myringoplasty Tympanoplasty
ndash + - Adenoidectomy
Indications for repair of perforation
bull Any Ear with cholesteatoma
bull Not healed spontaneously after 6 months observation
andhellip
bull Recurrent otorrhoea
bull Disabling conductive hearing loss bull Bilateral ( gt30 - 40 dB)
bull Unilateral
bull To allow watersports
Wullstein Classification of Tympanoplasty (1956)
bull Type I ndash Myringoplasty = 3 ossicles present amp drum repair
bull Type II ndash Malleusincus eroded ndash reconstruction preserves middle ear depth
bull Type III ndash Lateral ossicles gone graft onto stapes superstructure columella effect shallow ME cleft
bull Type IV ndash No ossicles graft onto footplate
bull Type V ndash graft onto fixed footplate Va = fenestration of LSSC
Tympoanoplasty Type 1 in children ndash an evaluative study
bull Gautam Bir Sing et al Int J Ped Otorninolaryngol 200569 (8)1071-76
bull 80 graft success rate at 6 month
bull 61 significant improved hearing
Meta-analysis of Pediatric Tympanoplasty
bull Vrabec et al Arch Otolaryngol H amp Neck Surg 1999 125 (5) 530-34
bull Graft take rate 80 in perf less than half TM
69 if over half TM
bull Take rate with good vs poor ET function 87 cf 77
bull Adenoids ndash no difference
bull Normal contralat ear vs abnormal 80 cf 71
bull Wet ear ndash no difference
bull Increased success rate with increasing Age (p =0005)
What Age to perform myringoplasty
bull Success rate not influenced by age (eg House Ear Institute
Chandrasekhar et al Arch Oto HampN Surg 1995 121873-878 and Denoyelle Garabedien group Paris Laryngoscope)
bull Mean age of most paediatric published series = 10 ndash 11 years (range 4 ndash 17)
bull General Advice (GMorrison) ndash Other ear predicts outcome ndash 7 ndash 8 yrs or over if infections controllable and one good
hearing ear ndash As early as 3 ndash 4 if bilat Subtotal perfs with disabling
hearing loss amp infections
Myringoplasty ndash Personal Surgical tips
bull Consider periosteum graft
bull Dry graft thoroughly
bull Trim graft to exact size (little finger nail)
bull Underlay or reverse thru-lay technique
bull ldquoKerrrdquo ant wall pocket if no anterior lip
bull Subcuticular resorbable sutures
bull BIPP pack(s) except v young
EAM
ME
Anterior
Cartilage Tympanoplasty
bull Jansen 1958
bull Heerman 1962 ndash cartilage palisade
bull Techniques
ndash Island graft
ndash Palisades
ndash Butterfly inlay
ndash Cartilage Shield
Indications for Cartilage Tympanoplasty
bull Retraction pockets
bull Atelectasis
bull Poor ET Function
bull To prevent prosthesis extrusion
bull (Revision Surgery)
Reinforcement Tympanoplasty for retraction
Post Cartilage Tympanoplasty amp Incus transposition
Surgical Outcomes for Paediatric Myringoplasty
bull Fat plug Myringoplasty ndash 80 success bull Paper - steristrip myringoplasty ndash 65 bull Formal Myringoplasty - over 80 closure - 60 - 81 hearing
success bull Hearing gain - ABG to lt 10 dB to 23 lt20 dB in 883
Risk of OME after repair ndash 78 Long term graft breakdown ndash 65
Wet Ear Surgery
bull Moist ear ndash OK
bull Purulent Ear ndash Surgery Contraindicated
Conclusions
bull AOM and CSOM without cholesteatoma can lead to intracranial complications
bull Persistent perforations post grommets are seen in up to 46 patients
bull Operate when ET function improved
bull Cartilage Tympanoplasty has advantages in special cases
bull You can routinely repair ears at 8 years
bull Surgery best avoided in a purulent ear
Thank You
Aetiologies of TM Perforations
bull AOM perforation bull Otitis Externa ndash myringitis (fungal) bull CSOM bull Specific Chronic Suppurative Otitis Media TB Actinomyces Syphilis
bull Direct trauma to membrane bull Post ventilation tubes (275 ear 46 child 13 t-tubes)
bull Barotraumatic bull Blast Injury beware implantation
cholesteatoma
Size Matters
bull Conductive Hearing Loss variable 0 ndash 50 dB
bull Larger perforation = larger ABG
bull Low frequencies greatest affected
bull Post frac12 TM ndash transmits low frequency
bull Ant frac12 TM transmits high frequency
Management of TM perforations
bull Conservative ldquoA small perforation is good it acts as a natural ventilation
tuberdquo
Small hole no infections good hearing poor ETD = leave alone
bull Surgical ldquoThe perforation is bad it leads to recurrent ear infections
and restricts water sportsrdquo
Recurrent infections hearing loss other ear good = repair
Management of TM perforations
bull Conservative
bull Swabs + microsuction
bull Keep ear dry (earplugs for swimming)
bull Topical Agents - Ofloxacin or Ciprofloxacin drops + steroids
bull Systemic antibiotics
Management of TM perforations
bull Surgical
ndash Myringoplasty Tympanoplasty
ndash + - Adenoidectomy
Indications for repair of perforation
bull Any Ear with cholesteatoma
bull Not healed spontaneously after 6 months observation
andhellip
bull Recurrent otorrhoea
bull Disabling conductive hearing loss bull Bilateral ( gt30 - 40 dB)
bull Unilateral
bull To allow watersports
Wullstein Classification of Tympanoplasty (1956)
bull Type I ndash Myringoplasty = 3 ossicles present amp drum repair
bull Type II ndash Malleusincus eroded ndash reconstruction preserves middle ear depth
bull Type III ndash Lateral ossicles gone graft onto stapes superstructure columella effect shallow ME cleft
bull Type IV ndash No ossicles graft onto footplate
bull Type V ndash graft onto fixed footplate Va = fenestration of LSSC
Tympoanoplasty Type 1 in children ndash an evaluative study
bull Gautam Bir Sing et al Int J Ped Otorninolaryngol 200569 (8)1071-76
bull 80 graft success rate at 6 month
bull 61 significant improved hearing
Meta-analysis of Pediatric Tympanoplasty
bull Vrabec et al Arch Otolaryngol H amp Neck Surg 1999 125 (5) 530-34
bull Graft take rate 80 in perf less than half TM
69 if over half TM
bull Take rate with good vs poor ET function 87 cf 77
bull Adenoids ndash no difference
bull Normal contralat ear vs abnormal 80 cf 71
bull Wet ear ndash no difference
bull Increased success rate with increasing Age (p =0005)
What Age to perform myringoplasty
bull Success rate not influenced by age (eg House Ear Institute
Chandrasekhar et al Arch Oto HampN Surg 1995 121873-878 and Denoyelle Garabedien group Paris Laryngoscope)
bull Mean age of most paediatric published series = 10 ndash 11 years (range 4 ndash 17)
bull General Advice (GMorrison) ndash Other ear predicts outcome ndash 7 ndash 8 yrs or over if infections controllable and one good
hearing ear ndash As early as 3 ndash 4 if bilat Subtotal perfs with disabling
hearing loss amp infections
Myringoplasty ndash Personal Surgical tips
bull Consider periosteum graft
bull Dry graft thoroughly
bull Trim graft to exact size (little finger nail)
bull Underlay or reverse thru-lay technique
bull ldquoKerrrdquo ant wall pocket if no anterior lip
bull Subcuticular resorbable sutures
bull BIPP pack(s) except v young
EAM
ME
Anterior
Cartilage Tympanoplasty
bull Jansen 1958
bull Heerman 1962 ndash cartilage palisade
bull Techniques
ndash Island graft
ndash Palisades
ndash Butterfly inlay
ndash Cartilage Shield
Indications for Cartilage Tympanoplasty
bull Retraction pockets
bull Atelectasis
bull Poor ET Function
bull To prevent prosthesis extrusion
bull (Revision Surgery)
Reinforcement Tympanoplasty for retraction
Post Cartilage Tympanoplasty amp Incus transposition
Surgical Outcomes for Paediatric Myringoplasty
bull Fat plug Myringoplasty ndash 80 success bull Paper - steristrip myringoplasty ndash 65 bull Formal Myringoplasty - over 80 closure - 60 - 81 hearing
success bull Hearing gain - ABG to lt 10 dB to 23 lt20 dB in 883
Risk of OME after repair ndash 78 Long term graft breakdown ndash 65
Wet Ear Surgery
bull Moist ear ndash OK
bull Purulent Ear ndash Surgery Contraindicated
Conclusions
bull AOM and CSOM without cholesteatoma can lead to intracranial complications
bull Persistent perforations post grommets are seen in up to 46 patients
bull Operate when ET function improved
bull Cartilage Tympanoplasty has advantages in special cases
bull You can routinely repair ears at 8 years
bull Surgery best avoided in a purulent ear
Thank You
Size Matters
bull Conductive Hearing Loss variable 0 ndash 50 dB
bull Larger perforation = larger ABG
bull Low frequencies greatest affected
bull Post frac12 TM ndash transmits low frequency
bull Ant frac12 TM transmits high frequency
Management of TM perforations
bull Conservative ldquoA small perforation is good it acts as a natural ventilation
tuberdquo
Small hole no infections good hearing poor ETD = leave alone
bull Surgical ldquoThe perforation is bad it leads to recurrent ear infections
and restricts water sportsrdquo
Recurrent infections hearing loss other ear good = repair
Management of TM perforations
bull Conservative
bull Swabs + microsuction
bull Keep ear dry (earplugs for swimming)
bull Topical Agents - Ofloxacin or Ciprofloxacin drops + steroids
bull Systemic antibiotics
Management of TM perforations
bull Surgical
ndash Myringoplasty Tympanoplasty
ndash + - Adenoidectomy
Indications for repair of perforation
bull Any Ear with cholesteatoma
bull Not healed spontaneously after 6 months observation
andhellip
bull Recurrent otorrhoea
bull Disabling conductive hearing loss bull Bilateral ( gt30 - 40 dB)
bull Unilateral
bull To allow watersports
Wullstein Classification of Tympanoplasty (1956)
bull Type I ndash Myringoplasty = 3 ossicles present amp drum repair
bull Type II ndash Malleusincus eroded ndash reconstruction preserves middle ear depth
bull Type III ndash Lateral ossicles gone graft onto stapes superstructure columella effect shallow ME cleft
bull Type IV ndash No ossicles graft onto footplate
bull Type V ndash graft onto fixed footplate Va = fenestration of LSSC
Tympoanoplasty Type 1 in children ndash an evaluative study
bull Gautam Bir Sing et al Int J Ped Otorninolaryngol 200569 (8)1071-76
bull 80 graft success rate at 6 month
bull 61 significant improved hearing
Meta-analysis of Pediatric Tympanoplasty
bull Vrabec et al Arch Otolaryngol H amp Neck Surg 1999 125 (5) 530-34
bull Graft take rate 80 in perf less than half TM
69 if over half TM
bull Take rate with good vs poor ET function 87 cf 77
bull Adenoids ndash no difference
bull Normal contralat ear vs abnormal 80 cf 71
bull Wet ear ndash no difference
bull Increased success rate with increasing Age (p =0005)
What Age to perform myringoplasty
bull Success rate not influenced by age (eg House Ear Institute
Chandrasekhar et al Arch Oto HampN Surg 1995 121873-878 and Denoyelle Garabedien group Paris Laryngoscope)
bull Mean age of most paediatric published series = 10 ndash 11 years (range 4 ndash 17)
bull General Advice (GMorrison) ndash Other ear predicts outcome ndash 7 ndash 8 yrs or over if infections controllable and one good
hearing ear ndash As early as 3 ndash 4 if bilat Subtotal perfs with disabling
hearing loss amp infections
Myringoplasty ndash Personal Surgical tips
bull Consider periosteum graft
bull Dry graft thoroughly
bull Trim graft to exact size (little finger nail)
bull Underlay or reverse thru-lay technique
bull ldquoKerrrdquo ant wall pocket if no anterior lip
bull Subcuticular resorbable sutures
bull BIPP pack(s) except v young
EAM
ME
Anterior
Cartilage Tympanoplasty
bull Jansen 1958
bull Heerman 1962 ndash cartilage palisade
bull Techniques
ndash Island graft
ndash Palisades
ndash Butterfly inlay
ndash Cartilage Shield
Indications for Cartilage Tympanoplasty
bull Retraction pockets
bull Atelectasis
bull Poor ET Function
bull To prevent prosthesis extrusion
bull (Revision Surgery)
Reinforcement Tympanoplasty for retraction
Post Cartilage Tympanoplasty amp Incus transposition
Surgical Outcomes for Paediatric Myringoplasty
bull Fat plug Myringoplasty ndash 80 success bull Paper - steristrip myringoplasty ndash 65 bull Formal Myringoplasty - over 80 closure - 60 - 81 hearing
success bull Hearing gain - ABG to lt 10 dB to 23 lt20 dB in 883
Risk of OME after repair ndash 78 Long term graft breakdown ndash 65
Wet Ear Surgery
bull Moist ear ndash OK
bull Purulent Ear ndash Surgery Contraindicated
Conclusions
bull AOM and CSOM without cholesteatoma can lead to intracranial complications
bull Persistent perforations post grommets are seen in up to 46 patients
bull Operate when ET function improved
bull Cartilage Tympanoplasty has advantages in special cases
bull You can routinely repair ears at 8 years
bull Surgery best avoided in a purulent ear
Thank You
Management of TM perforations
bull Conservative ldquoA small perforation is good it acts as a natural ventilation
tuberdquo
Small hole no infections good hearing poor ETD = leave alone
bull Surgical ldquoThe perforation is bad it leads to recurrent ear infections
and restricts water sportsrdquo
Recurrent infections hearing loss other ear good = repair
Management of TM perforations
bull Conservative
bull Swabs + microsuction
bull Keep ear dry (earplugs for swimming)
bull Topical Agents - Ofloxacin or Ciprofloxacin drops + steroids
bull Systemic antibiotics
Management of TM perforations
bull Surgical
ndash Myringoplasty Tympanoplasty
ndash + - Adenoidectomy
Indications for repair of perforation
bull Any Ear with cholesteatoma
bull Not healed spontaneously after 6 months observation
andhellip
bull Recurrent otorrhoea
bull Disabling conductive hearing loss bull Bilateral ( gt30 - 40 dB)
bull Unilateral
bull To allow watersports
Wullstein Classification of Tympanoplasty (1956)
bull Type I ndash Myringoplasty = 3 ossicles present amp drum repair
bull Type II ndash Malleusincus eroded ndash reconstruction preserves middle ear depth
bull Type III ndash Lateral ossicles gone graft onto stapes superstructure columella effect shallow ME cleft
bull Type IV ndash No ossicles graft onto footplate
bull Type V ndash graft onto fixed footplate Va = fenestration of LSSC
Tympoanoplasty Type 1 in children ndash an evaluative study
bull Gautam Bir Sing et al Int J Ped Otorninolaryngol 200569 (8)1071-76
bull 80 graft success rate at 6 month
bull 61 significant improved hearing
Meta-analysis of Pediatric Tympanoplasty
bull Vrabec et al Arch Otolaryngol H amp Neck Surg 1999 125 (5) 530-34
bull Graft take rate 80 in perf less than half TM
69 if over half TM
bull Take rate with good vs poor ET function 87 cf 77
bull Adenoids ndash no difference
bull Normal contralat ear vs abnormal 80 cf 71
bull Wet ear ndash no difference
bull Increased success rate with increasing Age (p =0005)
What Age to perform myringoplasty
bull Success rate not influenced by age (eg House Ear Institute
Chandrasekhar et al Arch Oto HampN Surg 1995 121873-878 and Denoyelle Garabedien group Paris Laryngoscope)
bull Mean age of most paediatric published series = 10 ndash 11 years (range 4 ndash 17)
bull General Advice (GMorrison) ndash Other ear predicts outcome ndash 7 ndash 8 yrs or over if infections controllable and one good
hearing ear ndash As early as 3 ndash 4 if bilat Subtotal perfs with disabling
hearing loss amp infections
Myringoplasty ndash Personal Surgical tips
bull Consider periosteum graft
bull Dry graft thoroughly
bull Trim graft to exact size (little finger nail)
bull Underlay or reverse thru-lay technique
bull ldquoKerrrdquo ant wall pocket if no anterior lip
bull Subcuticular resorbable sutures
bull BIPP pack(s) except v young
EAM
ME
Anterior
Cartilage Tympanoplasty
bull Jansen 1958
bull Heerman 1962 ndash cartilage palisade
bull Techniques
ndash Island graft
ndash Palisades
ndash Butterfly inlay
ndash Cartilage Shield
Indications for Cartilage Tympanoplasty
bull Retraction pockets
bull Atelectasis
bull Poor ET Function
bull To prevent prosthesis extrusion
bull (Revision Surgery)
Reinforcement Tympanoplasty for retraction
Post Cartilage Tympanoplasty amp Incus transposition
Surgical Outcomes for Paediatric Myringoplasty
bull Fat plug Myringoplasty ndash 80 success bull Paper - steristrip myringoplasty ndash 65 bull Formal Myringoplasty - over 80 closure - 60 - 81 hearing
success bull Hearing gain - ABG to lt 10 dB to 23 lt20 dB in 883
Risk of OME after repair ndash 78 Long term graft breakdown ndash 65
Wet Ear Surgery
bull Moist ear ndash OK
bull Purulent Ear ndash Surgery Contraindicated
Conclusions
bull AOM and CSOM without cholesteatoma can lead to intracranial complications
bull Persistent perforations post grommets are seen in up to 46 patients
bull Operate when ET function improved
bull Cartilage Tympanoplasty has advantages in special cases
bull You can routinely repair ears at 8 years
bull Surgery best avoided in a purulent ear
Thank You
Management of TM perforations
bull Conservative
bull Swabs + microsuction
bull Keep ear dry (earplugs for swimming)
bull Topical Agents - Ofloxacin or Ciprofloxacin drops + steroids
bull Systemic antibiotics
Management of TM perforations
bull Surgical
ndash Myringoplasty Tympanoplasty
ndash + - Adenoidectomy
Indications for repair of perforation
bull Any Ear with cholesteatoma
bull Not healed spontaneously after 6 months observation
andhellip
bull Recurrent otorrhoea
bull Disabling conductive hearing loss bull Bilateral ( gt30 - 40 dB)
bull Unilateral
bull To allow watersports
Wullstein Classification of Tympanoplasty (1956)
bull Type I ndash Myringoplasty = 3 ossicles present amp drum repair
bull Type II ndash Malleusincus eroded ndash reconstruction preserves middle ear depth
bull Type III ndash Lateral ossicles gone graft onto stapes superstructure columella effect shallow ME cleft
bull Type IV ndash No ossicles graft onto footplate
bull Type V ndash graft onto fixed footplate Va = fenestration of LSSC
Tympoanoplasty Type 1 in children ndash an evaluative study
bull Gautam Bir Sing et al Int J Ped Otorninolaryngol 200569 (8)1071-76
bull 80 graft success rate at 6 month
bull 61 significant improved hearing
Meta-analysis of Pediatric Tympanoplasty
bull Vrabec et al Arch Otolaryngol H amp Neck Surg 1999 125 (5) 530-34
bull Graft take rate 80 in perf less than half TM
69 if over half TM
bull Take rate with good vs poor ET function 87 cf 77
bull Adenoids ndash no difference
bull Normal contralat ear vs abnormal 80 cf 71
bull Wet ear ndash no difference
bull Increased success rate with increasing Age (p =0005)
What Age to perform myringoplasty
bull Success rate not influenced by age (eg House Ear Institute
Chandrasekhar et al Arch Oto HampN Surg 1995 121873-878 and Denoyelle Garabedien group Paris Laryngoscope)
bull Mean age of most paediatric published series = 10 ndash 11 years (range 4 ndash 17)
bull General Advice (GMorrison) ndash Other ear predicts outcome ndash 7 ndash 8 yrs or over if infections controllable and one good
hearing ear ndash As early as 3 ndash 4 if bilat Subtotal perfs with disabling
hearing loss amp infections
Myringoplasty ndash Personal Surgical tips
bull Consider periosteum graft
bull Dry graft thoroughly
bull Trim graft to exact size (little finger nail)
bull Underlay or reverse thru-lay technique
bull ldquoKerrrdquo ant wall pocket if no anterior lip
bull Subcuticular resorbable sutures
bull BIPP pack(s) except v young
EAM
ME
Anterior
Cartilage Tympanoplasty
bull Jansen 1958
bull Heerman 1962 ndash cartilage palisade
bull Techniques
ndash Island graft
ndash Palisades
ndash Butterfly inlay
ndash Cartilage Shield
Indications for Cartilage Tympanoplasty
bull Retraction pockets
bull Atelectasis
bull Poor ET Function
bull To prevent prosthesis extrusion
bull (Revision Surgery)
Reinforcement Tympanoplasty for retraction
Post Cartilage Tympanoplasty amp Incus transposition
Surgical Outcomes for Paediatric Myringoplasty
bull Fat plug Myringoplasty ndash 80 success bull Paper - steristrip myringoplasty ndash 65 bull Formal Myringoplasty - over 80 closure - 60 - 81 hearing
success bull Hearing gain - ABG to lt 10 dB to 23 lt20 dB in 883
Risk of OME after repair ndash 78 Long term graft breakdown ndash 65
Wet Ear Surgery
bull Moist ear ndash OK
bull Purulent Ear ndash Surgery Contraindicated
Conclusions
bull AOM and CSOM without cholesteatoma can lead to intracranial complications
bull Persistent perforations post grommets are seen in up to 46 patients
bull Operate when ET function improved
bull Cartilage Tympanoplasty has advantages in special cases
bull You can routinely repair ears at 8 years
bull Surgery best avoided in a purulent ear
Thank You
Management of TM perforations
bull Surgical
ndash Myringoplasty Tympanoplasty
ndash + - Adenoidectomy
Indications for repair of perforation
bull Any Ear with cholesteatoma
bull Not healed spontaneously after 6 months observation
andhellip
bull Recurrent otorrhoea
bull Disabling conductive hearing loss bull Bilateral ( gt30 - 40 dB)
bull Unilateral
bull To allow watersports
Wullstein Classification of Tympanoplasty (1956)
bull Type I ndash Myringoplasty = 3 ossicles present amp drum repair
bull Type II ndash Malleusincus eroded ndash reconstruction preserves middle ear depth
bull Type III ndash Lateral ossicles gone graft onto stapes superstructure columella effect shallow ME cleft
bull Type IV ndash No ossicles graft onto footplate
bull Type V ndash graft onto fixed footplate Va = fenestration of LSSC
Tympoanoplasty Type 1 in children ndash an evaluative study
bull Gautam Bir Sing et al Int J Ped Otorninolaryngol 200569 (8)1071-76
bull 80 graft success rate at 6 month
bull 61 significant improved hearing
Meta-analysis of Pediatric Tympanoplasty
bull Vrabec et al Arch Otolaryngol H amp Neck Surg 1999 125 (5) 530-34
bull Graft take rate 80 in perf less than half TM
69 if over half TM
bull Take rate with good vs poor ET function 87 cf 77
bull Adenoids ndash no difference
bull Normal contralat ear vs abnormal 80 cf 71
bull Wet ear ndash no difference
bull Increased success rate with increasing Age (p =0005)
What Age to perform myringoplasty
bull Success rate not influenced by age (eg House Ear Institute
Chandrasekhar et al Arch Oto HampN Surg 1995 121873-878 and Denoyelle Garabedien group Paris Laryngoscope)
bull Mean age of most paediatric published series = 10 ndash 11 years (range 4 ndash 17)
bull General Advice (GMorrison) ndash Other ear predicts outcome ndash 7 ndash 8 yrs or over if infections controllable and one good
hearing ear ndash As early as 3 ndash 4 if bilat Subtotal perfs with disabling
hearing loss amp infections
Myringoplasty ndash Personal Surgical tips
bull Consider periosteum graft
bull Dry graft thoroughly
bull Trim graft to exact size (little finger nail)
bull Underlay or reverse thru-lay technique
bull ldquoKerrrdquo ant wall pocket if no anterior lip
bull Subcuticular resorbable sutures
bull BIPP pack(s) except v young
EAM
ME
Anterior
Cartilage Tympanoplasty
bull Jansen 1958
bull Heerman 1962 ndash cartilage palisade
bull Techniques
ndash Island graft
ndash Palisades
ndash Butterfly inlay
ndash Cartilage Shield
Indications for Cartilage Tympanoplasty
bull Retraction pockets
bull Atelectasis
bull Poor ET Function
bull To prevent prosthesis extrusion
bull (Revision Surgery)
Reinforcement Tympanoplasty for retraction
Post Cartilage Tympanoplasty amp Incus transposition
Surgical Outcomes for Paediatric Myringoplasty
bull Fat plug Myringoplasty ndash 80 success bull Paper - steristrip myringoplasty ndash 65 bull Formal Myringoplasty - over 80 closure - 60 - 81 hearing
success bull Hearing gain - ABG to lt 10 dB to 23 lt20 dB in 883
Risk of OME after repair ndash 78 Long term graft breakdown ndash 65
Wet Ear Surgery
bull Moist ear ndash OK
bull Purulent Ear ndash Surgery Contraindicated
Conclusions
bull AOM and CSOM without cholesteatoma can lead to intracranial complications
bull Persistent perforations post grommets are seen in up to 46 patients
bull Operate when ET function improved
bull Cartilage Tympanoplasty has advantages in special cases
bull You can routinely repair ears at 8 years
bull Surgery best avoided in a purulent ear
Thank You
Indications for repair of perforation
bull Any Ear with cholesteatoma
bull Not healed spontaneously after 6 months observation
andhellip
bull Recurrent otorrhoea
bull Disabling conductive hearing loss bull Bilateral ( gt30 - 40 dB)
bull Unilateral
bull To allow watersports
Wullstein Classification of Tympanoplasty (1956)
bull Type I ndash Myringoplasty = 3 ossicles present amp drum repair
bull Type II ndash Malleusincus eroded ndash reconstruction preserves middle ear depth
bull Type III ndash Lateral ossicles gone graft onto stapes superstructure columella effect shallow ME cleft
bull Type IV ndash No ossicles graft onto footplate
bull Type V ndash graft onto fixed footplate Va = fenestration of LSSC
Tympoanoplasty Type 1 in children ndash an evaluative study
bull Gautam Bir Sing et al Int J Ped Otorninolaryngol 200569 (8)1071-76
bull 80 graft success rate at 6 month
bull 61 significant improved hearing
Meta-analysis of Pediatric Tympanoplasty
bull Vrabec et al Arch Otolaryngol H amp Neck Surg 1999 125 (5) 530-34
bull Graft take rate 80 in perf less than half TM
69 if over half TM
bull Take rate with good vs poor ET function 87 cf 77
bull Adenoids ndash no difference
bull Normal contralat ear vs abnormal 80 cf 71
bull Wet ear ndash no difference
bull Increased success rate with increasing Age (p =0005)
What Age to perform myringoplasty
bull Success rate not influenced by age (eg House Ear Institute
Chandrasekhar et al Arch Oto HampN Surg 1995 121873-878 and Denoyelle Garabedien group Paris Laryngoscope)
bull Mean age of most paediatric published series = 10 ndash 11 years (range 4 ndash 17)
bull General Advice (GMorrison) ndash Other ear predicts outcome ndash 7 ndash 8 yrs or over if infections controllable and one good
hearing ear ndash As early as 3 ndash 4 if bilat Subtotal perfs with disabling
hearing loss amp infections
Myringoplasty ndash Personal Surgical tips
bull Consider periosteum graft
bull Dry graft thoroughly
bull Trim graft to exact size (little finger nail)
bull Underlay or reverse thru-lay technique
bull ldquoKerrrdquo ant wall pocket if no anterior lip
bull Subcuticular resorbable sutures
bull BIPP pack(s) except v young
EAM
ME
Anterior
Cartilage Tympanoplasty
bull Jansen 1958
bull Heerman 1962 ndash cartilage palisade
bull Techniques
ndash Island graft
ndash Palisades
ndash Butterfly inlay
ndash Cartilage Shield
Indications for Cartilage Tympanoplasty
bull Retraction pockets
bull Atelectasis
bull Poor ET Function
bull To prevent prosthesis extrusion
bull (Revision Surgery)
Reinforcement Tympanoplasty for retraction
Post Cartilage Tympanoplasty amp Incus transposition
Surgical Outcomes for Paediatric Myringoplasty
bull Fat plug Myringoplasty ndash 80 success bull Paper - steristrip myringoplasty ndash 65 bull Formal Myringoplasty - over 80 closure - 60 - 81 hearing
success bull Hearing gain - ABG to lt 10 dB to 23 lt20 dB in 883
Risk of OME after repair ndash 78 Long term graft breakdown ndash 65
Wet Ear Surgery
bull Moist ear ndash OK
bull Purulent Ear ndash Surgery Contraindicated
Conclusions
bull AOM and CSOM without cholesteatoma can lead to intracranial complications
bull Persistent perforations post grommets are seen in up to 46 patients
bull Operate when ET function improved
bull Cartilage Tympanoplasty has advantages in special cases
bull You can routinely repair ears at 8 years
bull Surgery best avoided in a purulent ear
Thank You
Wullstein Classification of Tympanoplasty (1956)
bull Type I ndash Myringoplasty = 3 ossicles present amp drum repair
bull Type II ndash Malleusincus eroded ndash reconstruction preserves middle ear depth
bull Type III ndash Lateral ossicles gone graft onto stapes superstructure columella effect shallow ME cleft
bull Type IV ndash No ossicles graft onto footplate
bull Type V ndash graft onto fixed footplate Va = fenestration of LSSC
Tympoanoplasty Type 1 in children ndash an evaluative study
bull Gautam Bir Sing et al Int J Ped Otorninolaryngol 200569 (8)1071-76
bull 80 graft success rate at 6 month
bull 61 significant improved hearing
Meta-analysis of Pediatric Tympanoplasty
bull Vrabec et al Arch Otolaryngol H amp Neck Surg 1999 125 (5) 530-34
bull Graft take rate 80 in perf less than half TM
69 if over half TM
bull Take rate with good vs poor ET function 87 cf 77
bull Adenoids ndash no difference
bull Normal contralat ear vs abnormal 80 cf 71
bull Wet ear ndash no difference
bull Increased success rate with increasing Age (p =0005)
What Age to perform myringoplasty
bull Success rate not influenced by age (eg House Ear Institute
Chandrasekhar et al Arch Oto HampN Surg 1995 121873-878 and Denoyelle Garabedien group Paris Laryngoscope)
bull Mean age of most paediatric published series = 10 ndash 11 years (range 4 ndash 17)
bull General Advice (GMorrison) ndash Other ear predicts outcome ndash 7 ndash 8 yrs or over if infections controllable and one good
hearing ear ndash As early as 3 ndash 4 if bilat Subtotal perfs with disabling
hearing loss amp infections
Myringoplasty ndash Personal Surgical tips
bull Consider periosteum graft
bull Dry graft thoroughly
bull Trim graft to exact size (little finger nail)
bull Underlay or reverse thru-lay technique
bull ldquoKerrrdquo ant wall pocket if no anterior lip
bull Subcuticular resorbable sutures
bull BIPP pack(s) except v young
EAM
ME
Anterior
Cartilage Tympanoplasty
bull Jansen 1958
bull Heerman 1962 ndash cartilage palisade
bull Techniques
ndash Island graft
ndash Palisades
ndash Butterfly inlay
ndash Cartilage Shield
Indications for Cartilage Tympanoplasty
bull Retraction pockets
bull Atelectasis
bull Poor ET Function
bull To prevent prosthesis extrusion
bull (Revision Surgery)
Reinforcement Tympanoplasty for retraction
Post Cartilage Tympanoplasty amp Incus transposition
Surgical Outcomes for Paediatric Myringoplasty
bull Fat plug Myringoplasty ndash 80 success bull Paper - steristrip myringoplasty ndash 65 bull Formal Myringoplasty - over 80 closure - 60 - 81 hearing
success bull Hearing gain - ABG to lt 10 dB to 23 lt20 dB in 883
Risk of OME after repair ndash 78 Long term graft breakdown ndash 65
Wet Ear Surgery
bull Moist ear ndash OK
bull Purulent Ear ndash Surgery Contraindicated
Conclusions
bull AOM and CSOM without cholesteatoma can lead to intracranial complications
bull Persistent perforations post grommets are seen in up to 46 patients
bull Operate when ET function improved
bull Cartilage Tympanoplasty has advantages in special cases
bull You can routinely repair ears at 8 years
bull Surgery best avoided in a purulent ear
Thank You
Tympoanoplasty Type 1 in children ndash an evaluative study
bull Gautam Bir Sing et al Int J Ped Otorninolaryngol 200569 (8)1071-76
bull 80 graft success rate at 6 month
bull 61 significant improved hearing
Meta-analysis of Pediatric Tympanoplasty
bull Vrabec et al Arch Otolaryngol H amp Neck Surg 1999 125 (5) 530-34
bull Graft take rate 80 in perf less than half TM
69 if over half TM
bull Take rate with good vs poor ET function 87 cf 77
bull Adenoids ndash no difference
bull Normal contralat ear vs abnormal 80 cf 71
bull Wet ear ndash no difference
bull Increased success rate with increasing Age (p =0005)
What Age to perform myringoplasty
bull Success rate not influenced by age (eg House Ear Institute
Chandrasekhar et al Arch Oto HampN Surg 1995 121873-878 and Denoyelle Garabedien group Paris Laryngoscope)
bull Mean age of most paediatric published series = 10 ndash 11 years (range 4 ndash 17)
bull General Advice (GMorrison) ndash Other ear predicts outcome ndash 7 ndash 8 yrs or over if infections controllable and one good
hearing ear ndash As early as 3 ndash 4 if bilat Subtotal perfs with disabling
hearing loss amp infections
Myringoplasty ndash Personal Surgical tips
bull Consider periosteum graft
bull Dry graft thoroughly
bull Trim graft to exact size (little finger nail)
bull Underlay or reverse thru-lay technique
bull ldquoKerrrdquo ant wall pocket if no anterior lip
bull Subcuticular resorbable sutures
bull BIPP pack(s) except v young
EAM
ME
Anterior
Cartilage Tympanoplasty
bull Jansen 1958
bull Heerman 1962 ndash cartilage palisade
bull Techniques
ndash Island graft
ndash Palisades
ndash Butterfly inlay
ndash Cartilage Shield
Indications for Cartilage Tympanoplasty
bull Retraction pockets
bull Atelectasis
bull Poor ET Function
bull To prevent prosthesis extrusion
bull (Revision Surgery)
Reinforcement Tympanoplasty for retraction
Post Cartilage Tympanoplasty amp Incus transposition
Surgical Outcomes for Paediatric Myringoplasty
bull Fat plug Myringoplasty ndash 80 success bull Paper - steristrip myringoplasty ndash 65 bull Formal Myringoplasty - over 80 closure - 60 - 81 hearing
success bull Hearing gain - ABG to lt 10 dB to 23 lt20 dB in 883
Risk of OME after repair ndash 78 Long term graft breakdown ndash 65
Wet Ear Surgery
bull Moist ear ndash OK
bull Purulent Ear ndash Surgery Contraindicated
Conclusions
bull AOM and CSOM without cholesteatoma can lead to intracranial complications
bull Persistent perforations post grommets are seen in up to 46 patients
bull Operate when ET function improved
bull Cartilage Tympanoplasty has advantages in special cases
bull You can routinely repair ears at 8 years
bull Surgery best avoided in a purulent ear
Thank You
Meta-analysis of Pediatric Tympanoplasty
bull Vrabec et al Arch Otolaryngol H amp Neck Surg 1999 125 (5) 530-34
bull Graft take rate 80 in perf less than half TM
69 if over half TM
bull Take rate with good vs poor ET function 87 cf 77
bull Adenoids ndash no difference
bull Normal contralat ear vs abnormal 80 cf 71
bull Wet ear ndash no difference
bull Increased success rate with increasing Age (p =0005)
What Age to perform myringoplasty
bull Success rate not influenced by age (eg House Ear Institute
Chandrasekhar et al Arch Oto HampN Surg 1995 121873-878 and Denoyelle Garabedien group Paris Laryngoscope)
bull Mean age of most paediatric published series = 10 ndash 11 years (range 4 ndash 17)
bull General Advice (GMorrison) ndash Other ear predicts outcome ndash 7 ndash 8 yrs or over if infections controllable and one good
hearing ear ndash As early as 3 ndash 4 if bilat Subtotal perfs with disabling
hearing loss amp infections
Myringoplasty ndash Personal Surgical tips
bull Consider periosteum graft
bull Dry graft thoroughly
bull Trim graft to exact size (little finger nail)
bull Underlay or reverse thru-lay technique
bull ldquoKerrrdquo ant wall pocket if no anterior lip
bull Subcuticular resorbable sutures
bull BIPP pack(s) except v young
EAM
ME
Anterior
Cartilage Tympanoplasty
bull Jansen 1958
bull Heerman 1962 ndash cartilage palisade
bull Techniques
ndash Island graft
ndash Palisades
ndash Butterfly inlay
ndash Cartilage Shield
Indications for Cartilage Tympanoplasty
bull Retraction pockets
bull Atelectasis
bull Poor ET Function
bull To prevent prosthesis extrusion
bull (Revision Surgery)
Reinforcement Tympanoplasty for retraction
Post Cartilage Tympanoplasty amp Incus transposition
Surgical Outcomes for Paediatric Myringoplasty
bull Fat plug Myringoplasty ndash 80 success bull Paper - steristrip myringoplasty ndash 65 bull Formal Myringoplasty - over 80 closure - 60 - 81 hearing
success bull Hearing gain - ABG to lt 10 dB to 23 lt20 dB in 883
Risk of OME after repair ndash 78 Long term graft breakdown ndash 65
Wet Ear Surgery
bull Moist ear ndash OK
bull Purulent Ear ndash Surgery Contraindicated
Conclusions
bull AOM and CSOM without cholesteatoma can lead to intracranial complications
bull Persistent perforations post grommets are seen in up to 46 patients
bull Operate when ET function improved
bull Cartilage Tympanoplasty has advantages in special cases
bull You can routinely repair ears at 8 years
bull Surgery best avoided in a purulent ear
Thank You
What Age to perform myringoplasty
bull Success rate not influenced by age (eg House Ear Institute
Chandrasekhar et al Arch Oto HampN Surg 1995 121873-878 and Denoyelle Garabedien group Paris Laryngoscope)
bull Mean age of most paediatric published series = 10 ndash 11 years (range 4 ndash 17)
bull General Advice (GMorrison) ndash Other ear predicts outcome ndash 7 ndash 8 yrs or over if infections controllable and one good
hearing ear ndash As early as 3 ndash 4 if bilat Subtotal perfs with disabling
hearing loss amp infections
Myringoplasty ndash Personal Surgical tips
bull Consider periosteum graft
bull Dry graft thoroughly
bull Trim graft to exact size (little finger nail)
bull Underlay or reverse thru-lay technique
bull ldquoKerrrdquo ant wall pocket if no anterior lip
bull Subcuticular resorbable sutures
bull BIPP pack(s) except v young
EAM
ME
Anterior
Cartilage Tympanoplasty
bull Jansen 1958
bull Heerman 1962 ndash cartilage palisade
bull Techniques
ndash Island graft
ndash Palisades
ndash Butterfly inlay
ndash Cartilage Shield
Indications for Cartilage Tympanoplasty
bull Retraction pockets
bull Atelectasis
bull Poor ET Function
bull To prevent prosthesis extrusion
bull (Revision Surgery)
Reinforcement Tympanoplasty for retraction
Post Cartilage Tympanoplasty amp Incus transposition
Surgical Outcomes for Paediatric Myringoplasty
bull Fat plug Myringoplasty ndash 80 success bull Paper - steristrip myringoplasty ndash 65 bull Formal Myringoplasty - over 80 closure - 60 - 81 hearing
success bull Hearing gain - ABG to lt 10 dB to 23 lt20 dB in 883
Risk of OME after repair ndash 78 Long term graft breakdown ndash 65
Wet Ear Surgery
bull Moist ear ndash OK
bull Purulent Ear ndash Surgery Contraindicated
Conclusions
bull AOM and CSOM without cholesteatoma can lead to intracranial complications
bull Persistent perforations post grommets are seen in up to 46 patients
bull Operate when ET function improved
bull Cartilage Tympanoplasty has advantages in special cases
bull You can routinely repair ears at 8 years
bull Surgery best avoided in a purulent ear
Thank You
Myringoplasty ndash Personal Surgical tips
bull Consider periosteum graft
bull Dry graft thoroughly
bull Trim graft to exact size (little finger nail)
bull Underlay or reverse thru-lay technique
bull ldquoKerrrdquo ant wall pocket if no anterior lip
bull Subcuticular resorbable sutures
bull BIPP pack(s) except v young
EAM
ME
Anterior
Cartilage Tympanoplasty
bull Jansen 1958
bull Heerman 1962 ndash cartilage palisade
bull Techniques
ndash Island graft
ndash Palisades
ndash Butterfly inlay
ndash Cartilage Shield
Indications for Cartilage Tympanoplasty
bull Retraction pockets
bull Atelectasis
bull Poor ET Function
bull To prevent prosthesis extrusion
bull (Revision Surgery)
Reinforcement Tympanoplasty for retraction
Post Cartilage Tympanoplasty amp Incus transposition
Surgical Outcomes for Paediatric Myringoplasty
bull Fat plug Myringoplasty ndash 80 success bull Paper - steristrip myringoplasty ndash 65 bull Formal Myringoplasty - over 80 closure - 60 - 81 hearing
success bull Hearing gain - ABG to lt 10 dB to 23 lt20 dB in 883
Risk of OME after repair ndash 78 Long term graft breakdown ndash 65
Wet Ear Surgery
bull Moist ear ndash OK
bull Purulent Ear ndash Surgery Contraindicated
Conclusions
bull AOM and CSOM without cholesteatoma can lead to intracranial complications
bull Persistent perforations post grommets are seen in up to 46 patients
bull Operate when ET function improved
bull Cartilage Tympanoplasty has advantages in special cases
bull You can routinely repair ears at 8 years
bull Surgery best avoided in a purulent ear
Thank You
EAM
ME
Anterior
Cartilage Tympanoplasty
bull Jansen 1958
bull Heerman 1962 ndash cartilage palisade
bull Techniques
ndash Island graft
ndash Palisades
ndash Butterfly inlay
ndash Cartilage Shield
Indications for Cartilage Tympanoplasty
bull Retraction pockets
bull Atelectasis
bull Poor ET Function
bull To prevent prosthesis extrusion
bull (Revision Surgery)
Reinforcement Tympanoplasty for retraction
Post Cartilage Tympanoplasty amp Incus transposition
Surgical Outcomes for Paediatric Myringoplasty
bull Fat plug Myringoplasty ndash 80 success bull Paper - steristrip myringoplasty ndash 65 bull Formal Myringoplasty - over 80 closure - 60 - 81 hearing
success bull Hearing gain - ABG to lt 10 dB to 23 lt20 dB in 883
Risk of OME after repair ndash 78 Long term graft breakdown ndash 65
Wet Ear Surgery
bull Moist ear ndash OK
bull Purulent Ear ndash Surgery Contraindicated
Conclusions
bull AOM and CSOM without cholesteatoma can lead to intracranial complications
bull Persistent perforations post grommets are seen in up to 46 patients
bull Operate when ET function improved
bull Cartilage Tympanoplasty has advantages in special cases
bull You can routinely repair ears at 8 years
bull Surgery best avoided in a purulent ear
Thank You
Cartilage Tympanoplasty
bull Jansen 1958
bull Heerman 1962 ndash cartilage palisade
bull Techniques
ndash Island graft
ndash Palisades
ndash Butterfly inlay
ndash Cartilage Shield
Indications for Cartilage Tympanoplasty
bull Retraction pockets
bull Atelectasis
bull Poor ET Function
bull To prevent prosthesis extrusion
bull (Revision Surgery)
Reinforcement Tympanoplasty for retraction
Post Cartilage Tympanoplasty amp Incus transposition
Surgical Outcomes for Paediatric Myringoplasty
bull Fat plug Myringoplasty ndash 80 success bull Paper - steristrip myringoplasty ndash 65 bull Formal Myringoplasty - over 80 closure - 60 - 81 hearing
success bull Hearing gain - ABG to lt 10 dB to 23 lt20 dB in 883
Risk of OME after repair ndash 78 Long term graft breakdown ndash 65
Wet Ear Surgery
bull Moist ear ndash OK
bull Purulent Ear ndash Surgery Contraindicated
Conclusions
bull AOM and CSOM without cholesteatoma can lead to intracranial complications
bull Persistent perforations post grommets are seen in up to 46 patients
bull Operate when ET function improved
bull Cartilage Tympanoplasty has advantages in special cases
bull You can routinely repair ears at 8 years
bull Surgery best avoided in a purulent ear
Thank You
Indications for Cartilage Tympanoplasty
bull Retraction pockets
bull Atelectasis
bull Poor ET Function
bull To prevent prosthesis extrusion
bull (Revision Surgery)
Reinforcement Tympanoplasty for retraction
Post Cartilage Tympanoplasty amp Incus transposition
Surgical Outcomes for Paediatric Myringoplasty
bull Fat plug Myringoplasty ndash 80 success bull Paper - steristrip myringoplasty ndash 65 bull Formal Myringoplasty - over 80 closure - 60 - 81 hearing
success bull Hearing gain - ABG to lt 10 dB to 23 lt20 dB in 883
Risk of OME after repair ndash 78 Long term graft breakdown ndash 65
Wet Ear Surgery
bull Moist ear ndash OK
bull Purulent Ear ndash Surgery Contraindicated
Conclusions
bull AOM and CSOM without cholesteatoma can lead to intracranial complications
bull Persistent perforations post grommets are seen in up to 46 patients
bull Operate when ET function improved
bull Cartilage Tympanoplasty has advantages in special cases
bull You can routinely repair ears at 8 years
bull Surgery best avoided in a purulent ear
Thank You
Reinforcement Tympanoplasty for retraction
Post Cartilage Tympanoplasty amp Incus transposition
Surgical Outcomes for Paediatric Myringoplasty
bull Fat plug Myringoplasty ndash 80 success bull Paper - steristrip myringoplasty ndash 65 bull Formal Myringoplasty - over 80 closure - 60 - 81 hearing
success bull Hearing gain - ABG to lt 10 dB to 23 lt20 dB in 883
Risk of OME after repair ndash 78 Long term graft breakdown ndash 65
Wet Ear Surgery
bull Moist ear ndash OK
bull Purulent Ear ndash Surgery Contraindicated
Conclusions
bull AOM and CSOM without cholesteatoma can lead to intracranial complications
bull Persistent perforations post grommets are seen in up to 46 patients
bull Operate when ET function improved
bull Cartilage Tympanoplasty has advantages in special cases
bull You can routinely repair ears at 8 years
bull Surgery best avoided in a purulent ear
Thank You
Post Cartilage Tympanoplasty amp Incus transposition
Surgical Outcomes for Paediatric Myringoplasty
bull Fat plug Myringoplasty ndash 80 success bull Paper - steristrip myringoplasty ndash 65 bull Formal Myringoplasty - over 80 closure - 60 - 81 hearing
success bull Hearing gain - ABG to lt 10 dB to 23 lt20 dB in 883
Risk of OME after repair ndash 78 Long term graft breakdown ndash 65
Wet Ear Surgery
bull Moist ear ndash OK
bull Purulent Ear ndash Surgery Contraindicated
Conclusions
bull AOM and CSOM without cholesteatoma can lead to intracranial complications
bull Persistent perforations post grommets are seen in up to 46 patients
bull Operate when ET function improved
bull Cartilage Tympanoplasty has advantages in special cases
bull You can routinely repair ears at 8 years
bull Surgery best avoided in a purulent ear
Thank You
Surgical Outcomes for Paediatric Myringoplasty
bull Fat plug Myringoplasty ndash 80 success bull Paper - steristrip myringoplasty ndash 65 bull Formal Myringoplasty - over 80 closure - 60 - 81 hearing
success bull Hearing gain - ABG to lt 10 dB to 23 lt20 dB in 883
Risk of OME after repair ndash 78 Long term graft breakdown ndash 65
Wet Ear Surgery
bull Moist ear ndash OK
bull Purulent Ear ndash Surgery Contraindicated
Conclusions
bull AOM and CSOM without cholesteatoma can lead to intracranial complications
bull Persistent perforations post grommets are seen in up to 46 patients
bull Operate when ET function improved
bull Cartilage Tympanoplasty has advantages in special cases
bull You can routinely repair ears at 8 years
bull Surgery best avoided in a purulent ear
Thank You
Wet Ear Surgery
bull Moist ear ndash OK
bull Purulent Ear ndash Surgery Contraindicated
Conclusions
bull AOM and CSOM without cholesteatoma can lead to intracranial complications
bull Persistent perforations post grommets are seen in up to 46 patients
bull Operate when ET function improved
bull Cartilage Tympanoplasty has advantages in special cases
bull You can routinely repair ears at 8 years
bull Surgery best avoided in a purulent ear
Thank You
Conclusions
bull AOM and CSOM without cholesteatoma can lead to intracranial complications
bull Persistent perforations post grommets are seen in up to 46 patients
bull Operate when ET function improved
bull Cartilage Tympanoplasty has advantages in special cases
bull You can routinely repair ears at 8 years
bull Surgery best avoided in a purulent ear
Thank You
Thank You